NICU

Question 1

List 5 examples of infants at risk of hypoglycemia

Answer 1

1. Infant of a diabetic mother
2. Weight <10th percentile (SGA)
3. Weight >90th percentile (LGA)
4. Intrauterine growth restriction (IUGR)
5. Perinatal asphyxia
6. Preterm infants (<37 weeks GA)
7. Maternal labetalol use
8. Late preterm exposure to antenatal steroids
9. Metabolic conditions (CPT-1 deficiency [Inuit infants in particular])
10. Syndromes associated with hypoglycemia (e.g. Beckwith-Wiedemann)

Question 2

List 5 clinical signs of neonatal hypoglycemia

Answer 2

• Jitteriness
• Irritability
• Cyanosis
• Respiratory distress (apnea or tachypnea)
• Tachycardia
• Temperature instability
• Feeding difficulties
• Neuro symptoms: hypotonia, poor suck, and seizures or coma

Question 3

Describe the expected physiological response to hypoglycemia for ketones, growth hormone, insulin, cortisol and catecholamines

Answer 3

Ketones: ↑

Growth hormone: ↑

Catecholamines:`↑

Cortisol: ↑

Insulin: ↓

Question 4

What is considered a low blood glucose measurement in the following populations?

<72 HOURS OF LIFE

DOCUMENTED HYPERINSULINISM

>72 HOURS OF LIFE

Answer 4

<72h = <2.8

Documented hyperinsulinism, >72h = <3.3

• If <2.8, do critical sample (if not already done)

Question 5

How long do you have to screen the following populations for hypoglycemia?:

IDM/LGA

SGA/preterm infants (<36wk GA)

Answer 5

IDM/LGA = 12 hours if levels remain ≥2.6

SGA/preterm infants (<36wks GA) = 24 hours if no feeding concerns and infant is well

• If there has been ≥1 reading <2.6, it is reasonable to screen 1-2 times on Day 2 to ensure levels remain above 2.6

Once 2 consecutive BG ≥2.6, continue monitoring pre-feed or every 3-6h.

Question 6

You plan on sending an infant home from the hospital who has been experiencing persistent hypoglycemia. What should you do prior to discharge?

Answer 6

1. A 5-6 hour fast prior to discharge
   
   • Maintenance of glucose level ≥3.3 at 4 and 5 hours postfeed should be documented before discharge is considered.
2. Underlying diagnosis for neonatal hypoglycemia should be ascertained and specific medical management initiated (e.g. diazoxide in hyperinsulinism)
3. Counsel parents regarding frequency of feeding, home blood glucose monitoring, medication delivery (if needed) or other treatment measures for hypoglycemia

Question 7

Describe the essential approaches to treating hypoglycemia in the newborn and their corresponding treatment options.

What are conjunctive treatments for hyperinsulinism and GH deficiency?

Answer 7

1. Increasing energy intake
   
   • Orally
     
     • Increase frequency of breasfeeding
     • Supplementing feeds (order of preference): EBM, donor milk, formula
       
       • 5mL/kg with 1st BG <2.6 (asymptomatic)
         
         • can be used for 2nd BG <2.6 WITH gel
       • 8mL/kg with 2nd BG <2.6 (asymptomatic)
     • Intrabuccal 40% dextrose gel (0.5mL/kg)
   • Intravenously
     
     • IV glucose
       
       • Wean once glucose levels stable for 12h
2. Mobilizing energy stores
   
   • Glucagon
   • Corticosteroids

Conjunctive treatments

• Hyperinsulinism
  
  • Diazoxide
  • Octreotide
• GH deficiency
  
  • recombinant GH

Question 8

What is one non-pharmacological measure that has been associated with reducing the incidence of hypoglycemia and may be considered in at-risk infants

Answer 8

Delaying the first bath

Question 9

List 3 indications for initiation of IV dextrose in a hypoglycemic infant.

What orders would you provide to initiate IV intervention? How would you change your management for persistent hypoglycemia?

Answer 9

1. Symptomatic or unwell
   
   • Give bolus 2mL/kg over 15 minutes, as well
2. If BG <1.8
3. Not tolerating feeds
4. BG <2.6 x 3 (failed 2 interventions PO)

Initial IV: 80mL/kg/day of D10W, repeat glucose check in 30 minutes (if delay in IV insertion, give 40% dextrose gel 0.5mL/kg)

• Increase D10W infusion q30min by 1mL/kg/h until within target range
• Then, calculate the lowest GIR the BG is within target range
  
  • GIR = infusion rate (ml/kg/h) x [dextrose] (%)/6
• Then, calculate the [D%W] needed to stay within maximum daily TFI
  
  • Can give up to D20W in peripheral line
• Check electrolytes in 8-12h
• Introduce enteral feeds as tolerated
  
  • Can breastfeed above TFI during transitional period (risk of over-hydration is low)
  • If supplemented: do not exceed 100mL/kg/day total
• Once glucose ≥2.6 x 12h, can start to wean IV
  
  • Repeat BG q3h until full enteral feeds and 2 normal BGs

HIGH GIR

• 8-10 → consider level 3 care + CVL
• >10 →
  
  • Medication
    
    • Initial: Glucagon 0.1-0.3mg/kg bolus or 10-30µg/kg/h)
    • Others: hydrocortisone, diazoxide, octreotide
  • if >72h need further investigation
    
    • Critical sample
      
      • plasma glucose, beta-hydroxybutyrate, insulin, GH, cortisol, acylcarnitine + carnitine profiles, bicarbonate, FFA, lactate
    • Endocrinology referral

Question 10

List 5 risk factors for Intraventricular or Intraparenchymal Hemorrhage

Answer 10

1. ROM > 72h
2. Breech delivery via SVD
3. Increased urgency of delivery
4. Hypothermia
5. Use of vasopressors and inotropes
6. HD-PDA
7. Hypocapnia
   
   • PCO2 <35mmHg = risk of PVL
   • PCO2 >60mmHg = risk of IVH
8. Pressure-limited ventilation
9. Early use of HFO
10. Transportation of preterm infant (noise, vibration, acceleration)

Question 11

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

Answer 11

First 72 hours = critical window

95% IVH/intraparenchymal lesions are detected by Day 5

Question 12

List 5 ways to prevent acute brain injury in preterm infants

Answer 12

1. Maintain PCO2 between 45-55mmHg (minimize lung injury/ BPD)
2. Normothermia
3. Antenatal corticosteroids (if ≥48h prior to birth)
4. Umbilical cord milking
5. Delayed cord clamping up to 180s
6. Neutral, midline head position with ↑HOB 30˚
7. Volume-targeted ventilation (for first 72h)
8. Nurturing environment (skin-to-skin contact, maternal voice exposure and interaction, light cycling, low noise level)

Question 13

What strategies can be used to prevent acute brain injury for all premature neonates < 35 weeks?

Answer 13

• Transfer at-risk mothers to tertiary care centre to deliver (if able)
• C-section for very preterm + malpresenting infant
• Delayed cord clamping (30-120s) if not in need of immediate resuscitation (consider cord milking in this case)
• Avoid inotropes with hypotension unless a combination of other signs are present (↑lactate, ↑CRT, ↓u/o, ↓cardiac output)
• Avoid lung hyperinflation (use volume-targeted ventilation)
• Treat hypotension with slowly infused bolus before inotropes + CXR
• Target PCO2 45-55mmHg to minimize lung injury + BPD
• Maintain head in neutral, midline position with ↑HOB 30˚

<35 weeks

• If risk of delivery in ≤7 days offer antenatal corticosteroids

<34 weeks

• If delivery imminent (≤24h) consider intrapartum MgSO4 (↓ risk of cerebral palsy)

<33 weeks

• Maternal antibiotic prophylaxis if PPROM and expecting to deliver
  
  • Penicillin + macrolide (if allergic to PCN → macrolide only)
• If PPROM, preterm labour, unexplained NRFHR or chorio:
  
  • BCx + Abx prophylaxis x 36-48h (until BCx negative)

<32 weeks

• Prevent hypothermia
  
  • Polyethylene bag or wrapping
  • Hat
  • Maintain room temperature between 25-26˚C
  • preheated radiant warmer with servo-control
  • Thermal mattress
• Consider prophylactic indomethacin or ibuprofen for high-risk extremely preterm infants

Question 14

List 3 goals of postnatal period care

Answer 14

1. Foster development of parenting skills
2. Promote physical well-being of mother and infant
3. Support relationship among mother, infant and family members
4. Strengthen the mother’s knowledge and confidence
5. Facilitate development of feeding skills

All parents should receive counselling on:

• Infant care
• Signs of illness and how to respond
• Infant safety - including safe sleep practices
• Importance of smoke-free environment

Question 15

What is the role of the health-care provider during the postnatal course?

Answer 15

1. Evaluate the infant’s physical health
2. Identify early problems
3. Assist with establishment of feeding
4. Observe parent-infant interaction
5. Identify psychosocial stressors

Question 16

Identify 2 populations that are at increased risk for readmission after postpartum discharge.

Answer 16

1. First-time parent
2. Low household income
3. Younger GA

Question 17

Identify 5 criteria that must be met prior to discharge of a healthy term infant.

Answer 17

1. CCHD performed and normal
2. Physical exam (with measurements) complete and documented with no additional in-hospital or ongoing observations or treatments needed
3. Temperature is stable (open cot, appropriately dressed)
4. Urine and at least 1 stool have been passed
5. ≥2 successful feeds documented
6. Maternal serologies reviewed and mother received all immunizations and/or medications
7. NBS complete at ≥24h (or arrangements to screen within first 7d confirmed)
8. Successful cardiorespiratory adaptation with normal, stable HR and RR
9. Hearing screen completed or scheduled
10. Bilirubin screening complete with appropriate follow-up PRN
11. Vitamin K and ophthalmia neonatorum prophylaxis given
12. Approved car seat in place + parents have demonstrated they can position the seat and secure infant properly

Must have an appropriate follow-up plan with scheduled visit 24-72h postdischarge

Question 18

List 2 PROS and 2 CONS of early discharge of dyad following delivery

Answer 18

PROS

• Facilitates family integration
• Enhances parent-infant bonding
• Allows mother to recover in quieter home environment with family support
• Decreases exposure to nosocomial infection

CONS

• Decreased parental education time
• Untimely identification of postnatal problems
• Increased readmissions for jaundice and dehydration
• Shorter duration of breastfeeding

Question 19

List 5 maternal and 5 infant risk factors for safe discharge after delivery

Answer 19

MATERNAL

• Young age
• Language barrier
• Inadequate housing
• Lack of family support
• Inadequate prenatal care
• Unstable parental relationships
• Medications/substance use - ETOH, drugs
• Depression
• Low educational level

INFANT

• Abnormal prenatal screen/ultrasound findings
• Birth weight
• Serologies not protective
• Risk factors for infection/sepsis
• Abnormal glucose homeostasis
• DDH
• Birth injury
• Apgar score, need for stabilization at birth +/- low umbilical pH
• Risk factors for early-onset neonatal jaundice

Question 20

Describe the types of hemorrhagic disease of the newborn, their expected time course and etiology

Answer 20

1. Early onset (<24h)
   
   • Maternal medications that inhibit vitamin K activity (antiepileptics)
2. Classic (2-7 days)
   
   • Low intake of vitamin K
3. Late onset (2-12 weeks up to 6mo) - typically ICH (50%)
   
   • Almost exclusively breastfed infants
     
     • low vitamin K intake
     • chronic malabsorption

Question 21

Describe the recommended management options to prevent hemorrhagic disease of the newborn including dosing.

Answer 21

• Parenteral Vitamin K
  
  • IM injection x 1 within 6h of delivery + after initial stabilization and maternal/newborn interaction
    
    • use pain minimizing strategies
  • Dosing
    
    • ≤1500g = 0.5mg
    • >1500g = 1mg
• Oral Vitamin K (less effective, ↑failure rate, takes 5 days to achieve same effect as IM)
  
  • 2mg with first feed, 2-4 weeks and 6-8 weeks

Question 22

List 4 indications for imaging the neonatal brain

Answer 22

1. Infection
2. Unexplained apneas
3. Neonatal encephalopathy (NE)
4. Suspected structural brain abnormalities
5. Metabolic disorders
6. Birth injuries

Question 23

List the imaging modalities available for imaging the neonatal brain, indications for their use and disadvantages

Answer 23

• Head Ultrasound
  
  • Indication: assessment for intraventricular hemorrhage
  • Advantages: safe, portable, readily available
  • Disadvantages: posterior fossa may not be well visualized, operator dependent, not useful for encephalopathy
• CT Head
  
  • Indication: Urgent situations (unstable infant), suspicion of trauma or skull fracture
  • Advantages: offers imaging when patient too unstable
  • Disadvantages: ionizing radiation, grey/white contrast is poor, underestimates severity of injuries to white matter
• MRI Brain (modality of choice for TERM brain)
  
  • Indications: Neonatal encephalopathy, metabolic disorders, structural concerns
  • Advantages: no radiation, improved diagnostic accuracy, no need for sedation
  • Disadvantages: higher costs

Question 24

Describe the recommended timing for imaging of the neonatal brain following hypoxic ischemic encephalopathy

What are the 2 patterns of injury that can be seen with HIE, their location and the type of impairment associated with it?

Answer 24

Timing: DOL 3-5 (if cooled → DOL 4-5) to confirm diagnosis + extent (if exam not consistent with MRI findings or diagnostic ambiguity exists, repeat MRI in 10-14 days [maximal injury visible at this time for watershed injuries])

Patterns of Injury

1. Watershed (50%) → cognitive impairment/language
   
   • Location: between major arterial supplies and deep in the sulci → cortical necrosis
   • Seen with prolonged partial hypoxia-ischemia
   • Impairment: cognitive impairment, predicts language outcomes
2. Basal ganglia/thalamic (25%) → CP
   
   • Location: deep grey matter → sensorimotor cortex
   • Seen with acute, profound hypoxia-ischemia
   • Impairment: If loss of normal signal intensity in PLIC (posterior limb of internal capsule) → associated with severe motor and cogntivie disability → CP

Question 25

What is the best imaging for neonatal stroke? What type of stroke is most common and where is its common location?

Answer 25

MRI Arterial infarction → LEFT MCA 1-2mo: injury evolves into tissue loss & cysts

Question 26

Where would you expect to find the injury caused from a bilirubin encephalopathy on MRI?

Answer 26

Globus pallidus + subthalamic nuclei

Question 27

What is the inclusion criteria for therapeutic cooling for HIE? What are exclusions for therapeutic cooling? List 2.

Answer 27

Must be: * ≥36 weeks GA (possibly 35) * ≤6h of life * Meet Criteria A+C or B+C If meets criteria, but then returns to normal within 30-45min after birth, cooling may be deferred with careful ongoing observation for signs of returning encephalopathy. CRITERIA * **A:​** pH ≤7.0 or BE ≥-16 * **B:** pH 7.01-7.15 or BE -10 to -15.9 **AND** Apgar ≤5 at 10min or ≥10min PPV **AND** History of acute perinatal event (e.g. uterine rupture, placental abruption, cord prolapse) * **C:** Evidence of mod-severe encephalopathy - seizures or ≥3/6 categories with ≥1 sign present If criteria met, offer therapeutic cooling. If difficult to categorize, consult tertiary care neonatologist **EXCLUSIONS** * \<35 weeks GA * Clinically significant coagulopathy * Evidence of severe head trauma or intracranial bleeding * Moribund (in terminal decline) * Major congenital or genetic abnormalities for whom no further aggressive treatment is planned * Severe IUGR

Question 28

You are working in a community hospital and are caring for an infant with HIE who you have just determined meets criteria for therapeutic cooling. Describe strategies for initiation of cooling while awaiting transportation.

Answer 28

* Initiate passive cooling * Turn off warmer * Take off hat/blanket * Check rectal temperature q15min to prevent ≤33˚C (target is 33.5˚C ± 0.5˚C)

Question 29

Describe the possible complications with HIE/therapeutic cooling When would you consider discontinuing therapeutic cooling prematurely?

Answer 29

* Seizures * Discomfort (treat w/low dose morphine ≤10mcg/kg/h) 1. Hypotension despite inotropic support 2. PPHN with hypoxiemia despite adequate treatment 3. Clinically significant coagulopathy, despite treatment

Question 30

List 4 goals of therapeutic cooling for HIE How quickly should the baby be rewarmed?

Answer 30

1. Minimize fluctuations in CO2 2. Avoid hyperoxia 3. Ensure adequate tissue perfusion with appropriate use of vasopressors/intropes 4. Maintain normal blood glucose 5. Treat hyperbilirubinemia 6. Minimize unnecessary stimulation or handling Rewarming * After 72h of cooling, rewarm 0.5˚C q1-2h * if seizures/worsening encephalopathy - recool x 24h then resume warming * treat with antiepileptics - obtain serum levels in first 72h if redosing is needed

Question 31

How should follow-up be arranged for an infant with HIE who has received therapeutic cooling? What consequences/morbidity are you screening for with follow-up appointments?

Answer 31

* NNFU for minimum of 2y (ideally until school age) * Care by community pediatrician Consequences/morbidity 1. Cerebral palsy (30%) 2. Severe visual impairment/blindness (25%) 3. Hearing loss (~18%) 4. Learning disability (30-50%) 5. Behavioural difficulties 6. Epilepsy (13%, 7% require antiepileptics at school age)

Question 32

What is the most common type of neonatal sepsis? When does it typically present? What is the most common mechanism? What bacteria is most commonly responsible? What is the most common presenting symptom? What percentage of infants born to mothers colonized with GBS develop this type of sepsis without intrapartum antibiotic prophylaxis?

Answer 32

Early-onset neonatal bacterial sepsis Symptomatic within 24h of birth _Cause:_ vertical transmission of organisms colonizing birth canal *GBS,Escherichia coli, GAS, S. pneumoniae, Enterococcus, Enterobacter, Staph aureux, H. influenzae* Respiratory distress 1-2%

Question 33

List 4 risk factors for early-onset sepsis in the neonate

Answer 33

* Prolonged ROM \>18h * History of previous infant with invasive GBS disease * Maternal fever ≥38˚C * GBS bacteriuria at any time during the current pregnancy * Intrapartum GBS colonization during current pregnancy

Question 34

When should screening for GBS colonization be performed? If screening positive or history of GBS bacteriuria during the pregnancy, what is considered adequate prophylaxis? Does IAP decrease the incidence of late-onset GBS disease?

Answer 34

Between 35-37 weeks GA. Adequate prophylaxis = ≥4h prior to delivery for SVD or ROM (not needed for cold section) * IV Pen G 5 million units OR Ampicillin 2g (If allergy: Cefazolin IV 2g [low risk], or IV erythromycin/clindamycin or IV vancomycin) * Should be considered inadequate if IV clindamycin or IV vancomycin used (due to lack of clinical trials) No - does not decrease incidence of late-onset GBS disease

Question 35

What tests should be performed when concerned for early-onset bacterial sepsis in the neonate?

Answer 35

Tests * Blood culture * WBC \<5 x 10^9/L or ANC \<1.5 x 10^9/L * CBC/diff * If blood culture positive: * LP (should be done if BCx positive) * Considered positive if: WBC \>20-25cells/mm3 * pleocytosis, low glucose, high protein * CSF culture * If respiratory distress: * CXR

Question 36

List 5 signs of sepsis in a neonate.

Answer 36

1. Respiratory distress 2. Temperature instability 3. Tachycardia 4. Seizures 5. Hypotonia 6. Lethargy 7. Poor peripheral perfusion 8. Hypotension 9. Acidosis

Question 37

What is the management for early-onset neonatal sepsis?

Answer 37

Preterm (35-36wks) * if stable enough to remain with their mother, manage similar to term, but observe for 48h rather than 24h Term (≥37wks) * See photo Before discharge * Parents to understand signs of sepsis and are able to seek medical care if signs develop * Ready access to health care

Question 38

List 5 risk factors for acute encephalopathy in the presence of severe hyperbilirubinemia

Answer 38

1. Acidosis 2. Prematurity 3. Dehydration 4. Hyperosmolarity 5. Respiratory distress 6. Hydrops 7. Hypoalbuminemia 8. Hypoxia 9. Seizures

Question 39

List 5 risk factors for the development of severe hyperbilirubinemia in the newborn

Answer 39

* \<38wks gestational age * Previous sibling with severe hyperbilirubinemia * visible jaundice \<24h or before discharge * visible bruising * Male sex * Cephalohematoma * Maternal age ≥25yo * Asian or European background * Dehydration * Exclusive and partial breastfeeding

Question 40

When should a direct antiglobulin test be performed? When should a G6PD deficiency test be performed?

Answer 40

1. Clinically jaundiced infants of mothers with group O blood 2. Infants with elevated risk of needing therapy (high-intermediate risk zone) 3. Antenatal maternal antibodies **G6PD** * all infants with severe hyperbilirubinemia * screen at-risk infants (Mediterranean, Middle Eastern, African or Southeast Asian origin)

Question 41

At what level should a total conjugated bilirubin concentration prompt further investigation?

Answer 41

\>18 µmol/L or \>20% TSB concentration

Question 42

List 4 side effects of phototherapy.

Answer 42

1. Temperature instability 2. Intestinal hypermotility 3. Diarrhea 4. Interference with maternal-infant interaction 5. Bronze discolouration of the skin (rare)

Question 43

How should you manage an infant who presents with severe hyperbilirubinemia? Once ready for discharge, what follow-up should you arrange?

Answer 43

* Place under intensive phototherapy * Continue breastfeeding * Repeat bilirubin concentration within 2-6h of initiating treatment to confirm treatment response * Consider supplemental fluids administered orally or by IV infusion * If isoimmunization present, provide IVIG * If unsuccessful in controlling the rising bilirubin concentration, initiate exchange transfusion (consider in healthy term infant between 375-425 µmol/L) * Before starting: Collect blood for red cell fragility, enzyme deficiency and metabolic disorders, hemoglobin electrophoresis and chromosome analysis **Follow-up** * Breastfeeding support in community * Infants with isoimmunization: order repeat hemoglobin * If low at discharge: at 2 weeks * If normal at discharge: at 4 weeks * If exchange transfusion: * Refer for NNFU * Ensure hearing screen with brainstem auditory evoked potentials is completed

Question 44

Describe the recommended management for neonatal ocular prophylaxis during a shortage of erythromycin ointment What is the contraindication to administering Ceftriaxone in a neonate? What is the best means of preventing ophthalmia neonatorum?

Answer 44

* Gonorrhea * No test done → test mother at delivery\*\* * Positive test * Treated but not followed up → test mother at delivery\*\* * No treatment * Baby asymptomatic → assume baby is infected: test with conjunctival swab for gonococcus + IM/IV Ceftriaxone x 1 dose * Baby unwell → * Conjunctival swab + BCx + CSF Cx * Paediatric ID consult * Negative test * Low risk → no treatment * High-risk → test mother at delivery\*\* \*\*Discharge infant if close follow-up can be assured while awaiting results (counsel to contact immediately if develops eye irritation/discharge) If close follow-up CANNOT BE ASSURED **AND** it is NOT POSSIBLE for the infant to remain in hospital while awaiting results → treat with IM Ceftriaxone (50mg/kg [max 125mg]) x 1 before discharge * Chlamydia * Positive, no treatment → closely monitor for symptoms (conjunctivitis, pneumonitis) + treat if infection occurs **Contraindication -** if neonate is receiving IV calcium (administer cefotaxime 100mg/kg IM or IV) **Best prevention**: Screen pregnant mothers for gonorrhea and chlamydia infection (treat and follow-up those infected) * if positive, test after treatment to ensure therapeutic success * test again in 3rd trimester or at delivery

Question 45

What is the appropriate management of an infant exposed to *Chlamydia trachomatis*?

Answer 45

Close clinical follow-up Test conjunctival and nasopharygeal secretions of symptomatic infants → treat if positive Erythromycin PO 50mg/kg divided QID x 14 days

Question 46

What level of hematocrit is required for neonatal polycythemia? List 4 causes of neonatal polycythemia.

Answer 46

≥65% **Causes** 1. Passive fetal RBC transfusion * Twin-twin transfusion * Delayed cord clamping * Maternal-fetal transfusion 2. Increased fetal erythropoiesis * postdates * SGA * LGA * Infant of diabetic mother * Chromosomal abnormalities (trisomies 13, 18, 21) * Androgenital syndrome * Neonatal Graves disease * Hypothyroidism * Infants of hypertensive mothers (or taking propranolol) * Beckwith-Wiedemann Syndrome

Question 47

What is the most common cause of perinatal brachial plexus palsy (PBPP)? List 3 risk factors for PBPP. What is the prognosis?

Answer 47

Birth trauma **Risk factors for PBPP** * Shoulder dystocia * Large for gestational age * Maternal diabetes * Instrumental delivery **Prognosis:** * 75% recover completely within the first month of life * 25% will have residual deficits (if incomplete recovery by 3-4 weeks, full recovery is unlikely) * refer to multidisciplinary team

Question 48

What are the most frequent indications for blood transfusions in the newborn? Describe strategies to decrease risk of transfusion. What is a major risk of rapid and massive transfusion?

Answer 48

1. Acute treatment of perinatal or surgical hemorrhagic shock 2. 'top-ups' for recurrent correction of anemia of prematurity (used to maintain levels \>75) **Strategies to decrease risk of transfusion** 1. Leukoreduction (decreases CMV risk) 2. Irradiated (decreases GVHD risk) 3. Screening donors 4. Cross-matching (starting at 4mo) Implementing iron supplementation between 4-6wks of age (physiological 2-3mg/kg/day; if deficient: 4-6mg/kg/day) at onset of reticulocytosis, results in higher Hgb and iron stores after 6mo. **Risk of rapid/massive transfusion** = hyperkalemia

Question 49

What are the transfusion thresholds for anemia of prematurity?

Answer 49

**Week 1** * Resp support = 115 * No support = 100 **Week 2** * Resp support = 100 * No support = 85 **Week ≥3** * Resp support = 85 * No support = 75

Question 50

What are strategies to minimize iatrogenic blood loss in premature infants?

Answer 50

* Noninvasive CO2 monitoring for ventilated preterm infants * Noninvasive bilirubin monitoring devices before phototherapy is recommended * Point-of-care testing * Limit blood sampling to the minimum required for safe clinical care * Use marked tubes to indicate minimum volume to collect * Cluster blood samples to reduce skin breaks and painful procedures

Question 51

In what time period can Neonatal HSV infections present? List 2 prevention strategies for neonatal HSV. Describe 2 clinical presentations of neonates where you should consider neonatal HSV.

Answer 51

In the first 6 weeks of life (typically initial sx in first 4wks) **Prevention strategies** * C-section delivery * Maternal antiviral therapy * Anticipatory guidance for prospective mothers/partners * Identification of high-risk pregnancies **Clinical Presentations** * \<6wks * Suspected sepsis (esp. if presenting w/seizure, AbN CSF, not improving rapidly, -ve CSF at 24h, unexplained hepatitis) * Unexplained coagulopathy or bleeding from venipuncture sites * Pneumonia NYD, not improving after 24h Abx

Question 52

List the 3 classifications of maternal HSV and their risk of transmission.

Answer 52

1. Newly acquired * First-episode primary infection (no hx of antibodies) * 60% transmission * First-episode non-primary infection * ≤30% transmission 2. Recurrent * \< 2% transmission

Question 53

List the 3 classifications of neonatal HSV infections and the duration of treatment Which is most common in newly acquired maternal HSV? What indicates a poor prognosis?

Answer 53

* **Disseminated HSV** (involves multiple organs) **- 21 days** * **\***\*More common in newly acquired maternal HSV\*\* * Highest mortality rate (29%) * If nasopharyngeal PCR+ and pneumonia = presume disseminated * **Localized CNS HSV - 21 days** * **​**If fever, irritability and abnormal CSF findings (\*\*seizures) * Mortality rate (14%) * **Skin, eye and mucous membrane (SEM) infection - 14 days** **Poor prognosis** * Higher viral loads in CSF * Persistence of HSV in CSF in patients on acyclovir

Question 54

What is the recommended investigations/managements for: * Asymptomatic term infant potential exposed to HSV * Suspected 1st-episode genital HSV at delivery * Recurrent genital HSV * Symptomatic HSV

Answer 54

* **Asymptomatic term infant potential exposed to HSV** * **Suspected 1st-episode genital HSV at delivery** * Initial management * Mucous membrane swabs (conjunctivae, mouth, nasopharynx) at 24-hours of life regardless of delivery type +/- blood PCR (if available) * **​**Treatment with IV Acyclovir x 10 days for: * Vaginal delivery * C-Section delivery with ROM * C-section delivery NO ROM or Recurrent genital HSV: * Discharge to reliable caregiver aware of NHSV symptoms * Ongoing management * If HSV testing negative → continue observation * If HSV testing positive → admit to hospital * Do CSF + blood PCR + transaminases * Start Acyclovir IV * If CSF/blood positive → 21 days (min) * Repeat CSF near end of 21-day course, if remains positive, continue with weekly sampling until negative * If CSF/blood negative → 14 days * **Symptomatic HSV (or positive test in asymptomatic)** * Testing: * PCR testing: * CSF, mucous membrane swabs, vesicular lesions blood * Nasopharyngeal PCR if pneumonia present * Transaminases (evidence for disseminated) * **​**Start Acyclovir IV 60mg/kg/day divided q8h * If ocular involvement: * Treat with topical ophthalmic agent→ trifluridine * Ophthalmology consult * Suppressive therapy for CNS disease (consider for disseminated) * PO Acyclovir (300mg/m^2/dose TID) x 6 months * adjust for growth * CBC, urea/Cr monthly * Neonatal follow-up clinic

Question 55

Provide 1 infection control recommendation for each specific target group: Neonates with HSV infection and exposed neonates Mothers with active HSV Staff with orofacial or skin lesions

Answer 55

* **Neonates with HSV infection and exposed neonates** * ​Use contact precautions with: * Mucocutaneous lesions until crusted * Asymptomatic neonates whose mothers have active HSV lesions (until end of incubation period - 14 days) or until samples are negative * **Mothers with active HSV** * **​**Use contact precautions until lesions crusted * If herpes labialis, wear disposable mask when caring for infant \<6wks or until lesions healed (crusted and dried) * No kissing infant * Keep skin lesions covered whenever newborn present * **Staff with orofacial or skin lesions** * **​**Meticulous hand hygiene + keep lesions covered (if not possible, avoid direct care) * Wear surgical mask for orolabial lesions * Avoid contact if active herpetic whitlow

Question 56

Describe adverse effects associated with retinopathy of prematurity screening. List 2 methods to decrease these risks.

Answer 56

1. Distress 2. Pain 3. Apnea Decrease risks * Topical anesthetics * Pacifiers * Swaddling * Sucrose

Question 57

What are the screening recommendations for ROP?

Answer 57

* Screening: * \<31 weeks BGA * Start at 31wks CGA or 4 weeks of life (whichever is LATER) * BW≤1250g * BW 1251-2000g with unstable clinical course (respiratory disease, hypotension w/inotropes, prolonged ventilatory or oxygen therapy) Use of specialized digital retinal photography (RetCam) * should have ≥1 indirect ophthalmoscopic examination by an ophthalmologist before treatment or cessation of screening Discharged infants with ROP should be followed by an ophthalmologist (often have strabismus, cataracts, amblyopia and refractive errors)

Question 58

List 4 risks of surfactant replacement therapy

Answer 58

**Short-term risks** * During instillation * Bradycardia * Hypoxemia * Blockage of endotracheal tube * Pulmonary hemorrhage * Overdistension * Hyperventilation

Question 59

List 2 indications for surfactant replacement therapy

Answer 59

1. Intubated infants with RDS * should be administered before transport * \<29 weeks: consider immediate intubation followed by surfactant 2. Intubated infants with MAS requiring \>50% FiO2 3. Sick newborn infants with pneumonia and Oi \>15 4. Intubated infants with pulmonary hemorrhage which leads to clinical deterioration 5. Infants with RDS with persistent or recurrent oxygen (≥30%) and ventilatory requirements within the first 72h of life should have repeated doses of surfactant (maximum 3) * Can be considered as early as 2h after initial dose (more commonly 4-6h after)

Question 60

List 3 complications of maternal depression in the neonate Which SSRI may have an associated risk of increased cardiac malformations (septal, RVOT, conotruncal and LVOT defects)? How long should babies with late-trimester SSRI exposure be observed in hospital for neurobehavioural or respiratory symptoms?

Answer 60

1. Low birth weight 2. Preterm birth 3. Slightly higher risk of miscarriage 4. Respiratory distress 5. Increased length of hospital stay 6. Poor maternal-child bonding 7. Cognitive, behavioural and emotional consequences 8. With SSRI use: * PPHN (risk is negligible) * Admission to NICU Paroxetine Minimum of 48 hours

Question 61

List 4 signs or symptoms associated with SSRI exposure in the neonate (SSRI neonatal behavioural syndrome [SNBS]). When are these symptoms typically present and how long do they last?

Answer 61

1. Tachypnea 2. Cyanosis 3. Jitteriness/tremors 4. Increased muscle tone 5. Feeding disturbance Present within hours Resolve within 2 weeks

Question 62

Regarding twin-twin transfusion syndrome which vessel from the placenta is supplying the donor and recipient? List 4 complications associated with the donor List 4 complications associated with the recipient

Answer 62

* Donor→ arterial * Recipient → venous **Complications** * Donor * Oligohydramnios * Small for gestational age * Malnourished * Pale * Anemic * Hypovolemia * Hypoglycemia * Microcardia * Small glomeruli * Thin walled arterioles * Recipient * Polyhydramnios * Hydrops * Large for gestational age * Plethoric * Polycythemia * Hypervolemia * Cardiac hypertrophy * Myocardial dysfunction * Tricuspid regurgitation * Right ventricular outflow obstruction * Thick-walled arterioles * Large glomeruli

Question 63

Which 2 populations of infants are at highest risk for BPD? When are postnatal corticosteroids used to prevent BPD? What complication is associated with use of dexamethasone in the first 7 days of life?

Answer 63

**Highest risk for BPD** 1. Exposed to chorioamnionitis 2. \<28 weeks GA **When postnatal CS are used:** 1. Infants at highest risk for BPD: **Hydrocortisone** in the first 24-48h after birth x 10 days (risk of late-onset sepsis; do not combine with indomethacin) * _Physiologic replacement:_ 1mg/kg/d x 7d→ 0.5mg/kg/d x 3d * associated with increased survival without BPD 2. Infants who remain ventilated after 7d post birth with INCREASING O2 requirements + WORSENING lung disease * _Low-dose **Dexamethasone**_: 0.15-0.2mg/kg/d tapered over a short course (7-10d) **Dex \<7d of life:** increased risk of cerebral palsy

Question 64

List 4 contributing factors to BPD.

Answer 64

1. Early gestational age 2. Low birth weight 3. Lung barotrauma 4. Exposure to hyperoxia 5. Lung inflammation 6. Pre- and post-natal infections

Question 65

What is the criteria of an apnea in apnea of prematurity? Below what gestational age is at risk for apnea of prematurity? When should it resolve? How long should an infant have no apneas before considered safe for discharge

Answer 65

Cessation of breathing for ≥20s OR 10-20s if accompanied by bradycardia (\<80 bpm) or SpO2 \<37wks BGA \<35 weeks GA Typically by 40wks CGA (most by 36wks) (if BGA \<28wks, can continue until 44wks CGA) At least 5-7 days is suggested

Question 66

In infants born \<34 wks GA, what 4 factors indicate readiness for discharge? Parental factors? What is the recommended target SpO2 for infants with BPD?

Answer 66

1. **Thermoregulation** - maintain body temperature (~37˚C) fully clothed in an open cot 2. **Respiratory stability** - maintenance of SpO2 \>90-95% RA 3. **Feeding skills and sustained weight gain** - successful feeding by breast and/or bottle without major cardiorespiratory compromise 4. **Control of breathing** - apnea free for 5-7 days Parental (are able to:) 1. Independently and confidentaly care for their infant 2. Provide medications, nutritional supplements and any special medical care 3. Recognize signs and symptoms of illness and respond appropriately, especially in emergency situations 4. Understand the importance of infection control measures and a smoke-free environment SpO2 90-95%

Question 67

List 3 physiological changes associated with intubation List 2 ways these physiological responses can be reduced or eliminated.

Answer 67

1. Systemic and pulmonary hypertension * *Systemic HTN → adequate analgesia* 2. Bradycardia * *Can be avoided with atropine* 3. Intracranial hypertension * *Avoided with muscle relaxants* 4. Hypoxia * *Can be avoided with:* * *Preoxygenation* * *Use of blade that allows continuous oxygen insufflation into pharynx during procedure* **Reduced/Eliminated** 1. Vagolytics 2. Muscle relaxants 3. Analgesic 4. Preoxygenation 5. Gentle technique

Question 68

What are the complications of premedicating an infant for intubation? When is it acceptable to intubate an infant without premedication?

Answer 68

1. Chest wall rigidity (chest freeze) → potent short-acting opiates (avoided if given slowly, treated by giving a muscle relaxant or opioid antagonist) 2. Respiratory depression 3. Malignant hyperthermia, hyperkalemia, rhabdomyolysis → succinylcholine * Emergency intubations during resuscitation * Infants in whom instrumentation of the airway is likely to be extremely difficult (e.g. with severely abnormal airways + need to breathe on their own)

Question 69

List 2 indications for treatment with inhaled nitric oxide (iNO) What is the starting dose recommended? When should you consider weaning?

Answer 69

1. ≥35wks GA + hypoxemic respiratory failure failing to respond to respiratory management 2. OI (oxygenation index) \>20 to 25 3. PaO2 \<100mmHg despite 100% FiO2 4. May consider in premature infants with respiratory failure 2˚ oligohydramnios Not effective for most infants with CDH. **Starting dose**: 20ppm (should expect ↑PaO2 ≥20mmHg in ≤30min) * If no response, increase to 40ppm ( \>40ppm → potential for ↑toxicity without additional benefit) **Weaning:** Improvement in oxygenation AND 4-6h period of stability of ↓FiO2 to 60-80% or OI falls to ≤10. * ↓50% q4-6h (as long as OI ≤10) * Once 5ppm, ↓1ppm q4h and d/c at 1ppm if \<60% FiO2 w/PaO2 \>50mmHg constantly If cannot be weaned after 7 days, consider other lung/cardiac disease

Question 70

Name 2 risk factors associated with inhaled nitric oxide (iNO)

Question 71

List 2 populations where kangaroo care should be delayed

Answer 71

1. \<27wks GA who require high humidification 2. Abdominal wall defect (pre-op) 3. Neural tube defect (pre-op) 4. Newly postoperative patients (stability NYD) 5. Significant HD instability (wide BP swings, significant bradycardia, apnea or oxygen desaturation with handling, associated with prolonged recovery)

Question 72

List 4 benefits of kangaroo care in preterm infants Identify 2 barriers to implementation of kangaroo care.

Answer 72

1. Promotes maternal-infant bonding and breastfeeding * Breastfeeding: longer duration, higher volumes of milk expression, higher exclusive breastfeeding rates 2. Promotes stability of cardiorespiratory function and temperature 3. ↑ mature sleep organization (↑sleep time [quiet sleep], ↓active sleep) 4. ↓nosocomial infections 5. ↓pain with bedside procedures **Barriers to implementation** 1. Poor staff knowledge 2. Inadequate training 3. Discomfort with the process 4. Lack of time and/or resources 5. Lack of privacy 6. Parental reluctance

Question 73

List 2 reasons preterm infants are at lower risk for opioid withdrawal

Answer 73

1. Shorter in utero exposure time 2. Decreased placental transmission 3. Inability to fully excrete drugs by immature kidneys/liver 4. Minimal fat stores leading to lower deposition/activity of opioids

Question 74

What are 3 adverse effects of opioid use in pregnancy? How long should opioid-exposed babies be screened after delivery for withdrawal symptoms?

Answer 74

1. Prematurity 2. Low birth weight 3. Spontaneous abortion 4. SIDS 5. Infant neurobehavioural abnormalities 3-5 days

Question 75

List 4 non-pharmacological strategies to decrease symptoms from neonatal abstinence syndrome (NAS). What are 3 benefits of having the dyad room-in together during monitoring of NAS?

Answer 75

1. Skin-to-skin contact 2. Safe Swaddling 3. Quiet environment (lower lighting, minimal stimulation) 4. Music or Massage therapy 5. Gentle waking 6. Developmental positioning 7. Parent rooming in with baby (near term/term, medically stable, adequate support in place, ongoing assessment needed) **Benefits of Rooming-in** 1. Increased breastfeeding initiation rates 2. Lower NICU admissions 3. Less need for pharmacotherapy 4. Shorter hospital stays

Question 76

When should pharmacotherapy be initiated in Neonatal Abstinence Syndrome (NAS)? What is the recommended first line management? Describe available adjuncts for management. When can discharge be considered?

Answer 76

Using Finnegan scoring: 3 scores ≥8 OR 2 scores ≥12 * 1st line: morphine or methadone * morphine: 0.32mg/kg/day q4-6h PO (↓10% daily dose q48-72h) * 2nd line: Buprenorphine * Adjuncts: * Phenobarbital - **polysubstance abuse cases** * Clonidine - **autonomic symptoms present** **Discharge** * 72h if asymptomatic and no medication started * If phamacotherapy started: * Tolerating morphine wean * Consistent withdrawal scores \< 8 * Clear, documented weaning plan * When adequate medical and social follow-up available * Referral to PCP * Nutritional and family supportive resources * Infant neurodevelopmental assessment * Ensure safe, supportive home for discharge

Question 77

What is the most accurate assessment for determining gestational age? Describe the situations where palliative care, shared-care and intensive care would be recommended for extremely preterm infants. What are additional risk factors that would increase the likelihood of mortality in an extremely preterm infant.

Answer 77

First trimester crown-rump length with ultrasound (accurate within 3-8d) **Palliative Care** * 24wk GA w/ELBW (350g) * ≤22wks **Shared-care** * 23-24wks * 25wk w/fetal anemia and abnormal placental blood flow **Intensive Care** (antenatal CS should be given if this is an option + risk of delivery is high) * ≥25 wks * Late 24th wk, well growth with antenatal corticosteroids, born in a tertiary centre **Risk Factor** * SGA * No antenatal corticosteroids * Multiple gestations * GA early within week of gestation * Birth outside of a tertiary centre * Acute chorioamnionitis * Major congenital anomalies present on ultrasound

Question 78

List 2 benefits of human breast milk in the preterm infant. List 2 risks associated with donor breast milk. List 3 indications for donor breast milk.

Answer 78

1. Lower incidence of necrotizing enterocolitis 2. Lower incidence of severe infections 3. Reduced colonization by pathogenic organisms 4. Decreased length of hospital stay 5. Improved neurodevelopmental outcomes **Risks with PHDM** 1. Infection - screened for HBV, HCV, HIV, Human T cell leukemia virus 2. Contamination - "food poisoining" 3. Allergy 13% of protein content is denatured in PHDM. Carbohydrates, fats and solids are unchanged. All beneficial immune cells are inactivated (IgM antibodies completely removed) **Indications** * Prematurity * GI surgery * Malabsorption or Feeding intolerance * Immunodeficiency

Question 79

In standard-risk women of child-bearing age, what is recommended to prevent neural tube defects (NTD)? List 4 factors associated with increased risk for neural tube defect. What is recommended to prevent NTD in high-risk women?

Answer 79

* Encourage eating folate-rich foods (leafy vegetables, legumes, red meat, offal), fortified grain products * Daily multivitamin → Folate 0.4-1.0mg + Vitamin B12 * SOGC: 2-3mo before conception, throughout pregnancy + ≥6wks postpartum (or until breastfeeding stops) **Risk Factors** 1. Birth of previous child with NTD (*highest risk factor)* 2. Family history of NTD 3. Maternal obesity 4. Maternal Hispanic origin (or eat flour alternatives) 5. Use of some anticonvulsants 6. Low socioeconomic status (*greatest burden of NTD)* As above, except with Folate 5.0mg * SOGC: ≥3mo before conception → 10-12wks postpartum

Question 80

List 5 conditions that have been associated with Vitamin D deficiency List 2 conditions in the neonate that are associated with maternal Vitamin D deficiency

Answer 80

1. Osteoporosis 2. Asthma 3. Autoimmune diseases (RA, MS, IBD) 4. Diabetes 5. Disturbed muscle function 6. Resistance to Tuberculosis 7. Pathogenesis of certain types of cancer 8. Weak dental enamel **Neonatal conditions 2˚ Maternal Vit D Deficiency** 1. Rickets 2. Hypocalemia 3. Dental malformations

Question 81

What populations should receive 800IU/day of Vitamin D between October and April? What is the recommended dosing of Vitamin D for premature infants and infants during first year? What are the recommendations regarding maternal Vitamin D supplementation (pregnant/lactating women) to maintain sufficiency?

Answer 81

1. North of 55th parallel 2. Between 40th-55th parallel + RFs for Vit D deficiency (dark skin, breastfed, maternal deficiency) **Premature**: 200 IU/kg/day (max 400 IU/d) **Infants:** 400IU daily **Maternal:** Consider 2000 IU/day with monitoring of 25-OH Vit D and calcium for side effects.

Question 82

List 5 benefits of breastfeeding.

Answer 82

1. ↓ incidence of bacterial infections 2. ↓ hospital admissions 2˚ infection 3. ↓ severe respiratory illnesses 4. ↓ SIDS 5. ↑ performance on neurocognitive testing 6. Economical Maternal benefits 1. ↓ breast + ovarian cancers 2. ↑ postpartum weight loss 3. Delay in return of ovulation

Question 83

List 4 contraindications to breastfeeding excluding medications. List 4 medications or drugs contraindicated in breastfeeding.

Answer 83

Mothers: 1. HIV-positive 2. Human T-cell lymphotropic virus type 1 and 2 3. Active tuberculosis (until treated ≥2 weeks + not contagious) 4. Active HSV lesions on both breasts 5. Receiving cytotoxic chemotherapy (for duration of treatment) 6. Receiving radioactive isotopes or radiation therapy (during treatment course) Infants 1. Galactosemia **Medications** 1. Amphetamines 2. Cocaine 3. Cyclophosphamide 4. Clozapine 5. Doxorubicin 6. Ecstasy (MDMA) 7. Immunosuppressants 8. Heroin 9. Gold salts 10. Thiouracil

Question 84

At what age have children developed the advanced oral motor coordination required to properly handle chunky food pieces such as nuts, whole grapes and hot dog wheels?

Answer 84

3 years

Question 85

Identify the 2 types of approaches to cessation of breastfeeding.

Answer 85

1. Gradual weaning (infant-led) * occurs as the infant begins to accept increasing amounts of foods while still breastfeeding on demand. * Wean usually completes between 2-4yo 2. Planned weaning (mother-led) * Reasons: inadequate supply, concerns regarding infant growth, painful feedings or mastitis, returning to work, new pregnancy, wishing an alternate caregiver to give feedings, eruption of baby's teeth

Question 86

What guidance would you provide a mother whose infant has suddenly refused to breastfeed

Answer 86

"Nursing Strike" * Minimize Distractions: Make feeding time quiet and special * Increase cuddling and soothing of baby * Offer breast when infant is very sleepy or just waking up * Offer breast using different nursing positions, alternating sides or nursing in different rooms If this is not effective, a physician should evaluate the infant for presence of possible illness.

Question 87

In regards to hearing screening, what is the ideal timing for screening, confirmation of diagnosis and intervention? What is the average age at diagnosis in areas of Canada without screening programs? What is the most common type and cause of hearing loss in children?

Answer 87

* **Screening**: ≤1mo * **Confirmation of diagnosis**: ≤3mo * **Intervention:** ≤6mo Average age at diagnosis = ~24 months (2yo) **Most common type:** Sensorineural hearing loss **Most common cause**: 50% genetics (most common → error in production of gap junction protein *connexin 26*)

Question 88

List 4 risk factors for neonatal sensorineural hearing loss

Answer 88

* **ABCDs** * **A**ffected family member * **B**ilirubin * **C**ongenital intrauterine infection (CMV, rubella, toxo, HSV) * **D**efects of ear, nose and throat - Branchial Oto Renal syndrome + CHARGE syndrome (most common) * **S**mall at birth (\<1500g), low apgar, NICU * NICU stay \>2 days OR involving any of the following (regardless of duration): * ECMO * Assisted ventilation * Ototoxic drug use * Hyperbilirubinemia requiring exchange transfusion

Question 89

List 4 infections associated with congenital sensorineural hearing loss

Question 90

List 3 functional outcomes of delayed diagnosis/intervention of neonatal sensorineural hearing loss

Answer 90

1. Impaired socioemotional development * Low academic achievement * Underemployment * Increased social maladaption * Psychological distress 2. Decreased literacy

Question 91

What are the 2 types of hearing screening tests performed? Which is performed first in an newborn with no risk factors? Describe intervention strategies if hearing loss is detected.

Answer 91

1. OAE - otoacoustic emission (**1st if no RFs)** 2. AABR - automated auditory brainstem response (**if RFs)** * ​​tests for auditory neuropathy (vestibular nerve function) **Hearing loss intervention** * Audiological * Medical/surgical * Hearing aid * Cochlear implant * **eligible children for bilateral implants should receive them between 8-12mo + auditory oral therapy** * Bone-anchored hearing aid * Brainstem-implanted auditory device * Educational/(re)habilitation * Child and family support

Question 92

What is the recommended compression to ventilation ratio for neonatal resuscitation What is the preferred method of heart rate assessment when administering chest compressions? What initial FiO2 should you use for infants \<35 weeks What is the recommended dosing for epinephrine in neonatal resucitation? At what gestational age should you use strategies to optimize thermoregulation? What ETT tube size is recommended for a 3.75kg infant?

Answer 92

3 compressions: 1 ventilation Cardiac monitor 21-30% Epinephrine (1:10 000) ETT 1mL/kg (0.1mg/kg) [max 3mL]; IV 0.1mL/kg (0.01mg/kg) \<32 weeks GA ETT 3.5

Question 93

Describe the treatment for polycythemia

Answer 93

**Treatment** * Confirm hematocrit with venous sample * Treat dehydration * Closely monitor ins/outs, blood glucose and bilirubin levels * _Hct 60-70%_ * Monitor closely * Hydrate with enteral intake/administration of IV fluids * _Hct 70-75%_ + symptoms worsen despite aggressive IV hydration * Partial exchange transfusion (with NS)

Question 94

List 4 signs or symptoms of neonatal polycythemia. What are 2 complications associated with neonatal polycythemia?

Answer 94

**Signs/Symptoms** * Irritability * Lerthargy * Tachypnea * Respiratory distress * Cyanosis * Feeding disturbances * Hyperbilirubinemia * Hypoglycemia * Thrombocytopenia **Complications** * Stroke * Seizures * Pulmonary hypertension * Necrotizing enterocolitis * Renal vein thrombosis * Renal failure

Question 95

What 4 things can you do while waiting for the neonatal transport team to transfer your baby with PPHN (pH 7.32, pCO2 48, HCO3 18, FiO2 80%, SpO2 91% preductal, 82% postductal)?

Answer 95

1. Intubate and secure airway 2. Target normocarbia and correct acidosis 3. Obtain secure vascular access - insert UVC, possible UAC 4. Minimize handling 5. Provide sedation **Transportation** 1. Obtain copies of pertinent records and medical images 2. Obtain a maternal blood sample and colostrum for early feeding, if able 3. Retain the placenta, double-bagged in a sealed container without formaldehyde, for pathology examination

Question 96

What characteristic findings are seen on this CXR?

Answer 96

* Air bronchograms * Diffuse, fine reticular granularity of the parenchyma (ground-glass appearance) * Low lung volumes = Respiratory Distress Syndrome

Question 97

What characteristic findings are seen on this CXR?

Answer 97

* Prominent perihilar pulmonary vascular markings * Fluid in intralobar fissures * Rarely, small pleural effusions = Transient tachypnea of the newborn

Question 98

What characteristic findings are seen on this CXR?

Answer 98

* Patchy infiltrates * coarse streaking of both lung fields * increased AP diameter * Flattening of the hemidiaphram = Meconium aspiration syndrome

Question 99

List 4 clinical signs associated with neonatal thyrotoxicosis. How will you manage this infant?

Answer 99

1. Irritability 2. Tachycardia (including SVT +/- cardiac failure simulating cardiomyopathy) 3. Polycythemia 4. Craniosynostosis 5. Bone age advancement 6. Poor feeding 7. Failure to thrive **Management:** * Self-limited disease (can take up to 6mo) * May need methimazole and beta-blockers to control hyperthyroidism and cardiovascular symptoms * If minimally affected, observe without treatment

Question 100

What features are associated with / at risk in Infant of a Diabetic Mother?

Answer 100

* Preterm labour * LGA (or IUGR if vascular disease associated) * Hypoglycemia (25-50%) * Presents as jittery, tremulous, hyperexcitable * Hypocalcaemia * Hypomagnesemia * Tachypnea * Can be due to RDS (higher incidence) * Can be due to hypoglycemia, hypothermia, polycythemia, cardiac failure, TTN or cerebral edema from asphyxia/HIE * Cardiomegaly * 30% with 5-10% in heart failure * Asymmetric septal hypertrophy or transient hypertrophic subaortic stenosis * Hyperbilirubinemia from polycythemia * Renal vein thrombosis * Suspect if flank mass, hematuria and thrombocytopenia * Congenital anomalies * Congenital heart * VSD, ASD, TGA, truncus, DORV, tricuspid atresia, coarct * Lumbosacral agenesis * Neural tube defects * Hydronephrosis * Renal agenesis and dysplasia * Duodenal or anorectal atresia * Situs inversus * Double ureter * Holoprosencephaly * Small left colon syndrome (delayed development of left colon, transient, can have abdo distension)

Question 101

What are the differences in presentation of TORCH infections? (ie. Toxo, Rubella, CMV, HSV, Syphilis)

Answer 101

Question 102

Child with brachial plexus injury. How long before if no change in exam is prognosis poor? a. 1 month b. 3 month c. 9 month d. 1 year

Answer 102

b. 3 month - surgery indicated if function not improving by 3 months - more likely to be total nerve disruption or nerve root avulsion

Question 103

A term newborn is born to a heroin addicted mom. On initial assessment the baby is apneic but HR is greater than 100. After 30 seconds, the baby continues to be apneic despite adequate bag and mask ventilation. What is the next step in your management? a. IM Narcan b. Intubate and give Narcan down the ETT c. Continues to support ventilation until baby breathes on his own d. Epinephrine 1:10000

Answer 103

c. Continues to support ventilation until baby breathes on his own

Question 104

Full term baby delivered after traumatic forceps delivery. Now 1 month old with vomiting, lethargy and red plaque on back of hand. What lab test would you check. 1. Glucose 2. calcium 3. potassium 4. alp 5. creatinine

Answer 104

2. calcium - subcutaneous fat necrosis - rubbery/firm red/violaceous plaques or nodules on cheek, butt, back, thigh, arm A rare but potentially life-threatening complication is hypercalcemia. It manifests at 1-6 mo of age as lethargy, poor feeding, vomiting, failure to thrive, irritability, seizures, shortening of the QT interval on electrocardiography, or renal failure

Question 105

In counseling a woman who has had a child with a meningomyelocele, what would you tell her as regards her next pregnancy: a. take folic acid prior to conception and then for 10 weeks afterwards b. ultrasound at 16 weeks c. amniocentesis at 16 weeks d. alpha-fetoprotein at 16 weeks

Answer 105

ANSWER: a. take folic acid prior to conception and then for 10 weeks afterwards (PROBABLY THE MOST CORRECT BUT TECHNICALLY SOGC SAYS FOR FULL T1 and NELSON SAY TILL WEEK 12) \*b. ultrasound at 16 weeks (typically week 18-22) c. amniocentesis at 16 weeks (no only if US (+) then discuss) d. alpha-fetoprotein at 16 weeks (PIR routine in past; SOGC not routine now)

Question 106

IUGR neonate with bony changes, cataracts and hepatosplenomegaly. What’s the most likely diagnosis? a. congenital syphilis b. congenital rubella c. congenital CMV d. congenital toxoplasmosis

Answer 106

b. congenital rubella - neonatal findings: - IUGR, interstitial pneumonitis, radiolucent bone disease, HSM, TCP, dermal erythropoiesis (blueberry muffin lesions)

Question 107

Mom ivdu. Early latent syphilis. Titer from 6 months ago and now. They have dropped by 8 times. Baby is born. What do you do to for the baby: a) Observe b) Tryomonial screen and RPR c) CSF RPR d) Swab baby

Answer 107

b) Treponemal screen and RPR - mom with primary, secondary or early latent syphilis treated at least 4 weeks prior to delivery with at least 4 fold drop in titres - RPR and TT at 0, 3, 6, 18 months as well as clinical assessment monthly x3 months and with each additional serum screen

Question 108

Mom is IVDU. Her blood work: HEB B + HepC +. Baby’s blood work at 6 mo, hep B and hep C ab negative. What to do: a) Rest Hepc in 6 months b) No further investigations c) PCR

Answer 108

b) No further investigations - for a child at any age born to a mother with hep C who has absent Hep C antibodies, there is no need to test PCR and the interpretation is that either vertical transmission did not occur or the child cleared the infection

Question 109

Mom hep B positive. What do you do for baby ?

Answer 109

- Hep B vaccine at birth, 1-2m, 6m and HBIG as soon after delivery as possible (\<12h)

Question 110

Klehauer betke test - question about what it is

Answer 110

Used to determine if there is fetal blood in maternal circulation such as fetal maternal haemorrhage (test done on maternal blood sample)

Question 111

EcG: baby is thrombocytopenic, mild elevated liver enzymes, ecg shows complete heart block. What does mom have?

Answer 111

SLE (or other autoimmune condition like RA or Sjogren) - baby has congenital lupus

Question 112

You are examining a newborn infant, born at full term, 2600g. He has a flat nasal bridge, a thin upper lip and a smooth philtrum. He is mildly hyptonic. Which of the following ingestions is it important to inquire about in your history of the mother’s pregnancy: a. Cocaine b. Alcohol c. Marijuana d. Heroin

Answer 112

b. Alcohol

Question 113

Mother of 2 hour newborn who has a mass on the scalp that crosses suture lines. The mother took phenytoin during pregnancy and the child was delivered via vacuum delivery. Give two reasons why the child has this lesion.

Answer 113

in utero use of phenytoin (can predispose to bleeding) and caput succedaneum from vacuum

Question 114

Picture of a CT scan of the head with intracranial calcifications. What is the diagnosis?

Answer 114

Congenital CMV (periventricular calcifications, ventriculomegaly, microcephaly, HSM, TCP, SNHL, chorioretinitis), congenital toxoplasmosis (chorioretinitis, hydrocephalus and CNS lesions), HIV

Question 115

A 24 hr old newborn is seen with a report of scant U/O, the creat is 85. What is this most consistent with: a. Maternal creat b. Creat cannot be interpreted without a urea c. Creat is elevated for this newborn d. Creat cannot be interpreted without a urine creat

Answer 115

a. Maternal creat

Question 116

Which of the following are true? (a) fetal p02 is 25-30 (b) the incidence of asymptomatic PFO in the adult population is 10% c) Umbilical veins close before umbilical arteries

Answer 116

ANSWER: (a) fetal p02 is 25-30 (umbilical venous pO2 is 30-35 (highest pO2 in fetus), but it mixes with systemic blood so pO2 entering the RA is 26-28mmHg) (b) the incidence of asymptomatic PFO in the adult population is 10% - also true, it's 10-25%

Question 117

2-week old child with a 1 week history of stool mixed with blood in an infant? Bottlefeeding well, passed stool in first 24 hours. Most likely dx? a. anal fissure b. cow milk protein allergy enterocolitis c. Meckel’s diverticulum

Answer 117

b. cow milk protein allergy enterocolitis

Question 118

A 1 week old breastfed baby comes in to your office for newborn care. There is bright red blood mixed in with the stool. The baby did not have any bleeding or bruising with the Vitamin K injection at birth or with the newborn screen. The anus appears normal and there is no evidence of a fissure. List the most likely cause of the blood in the stool.

Answer 118

Cow’s milk protein intolerance

Question 119

All of the following are normal in term newborns except: a) Hypotonia post feed b) Irregular respiratory pattern in REM sleep c) Sigh following a brief period of apnea d) Mild cyanosis with feeding

Answer 119

d) Mild cyanosis with feeding

Question 120

1 mo 2 day old with a vesicle noted on the upper lip? a. Sucking blister b. HSV c. Varicella d. Epidermolysis bullosa

Answer 120

a. Sucking blister - Sucking Pads o Calluses/vesicles found on lips in first few months o Confirmed by observing neonate sucking the affected area

Question 121

2 month old baby with poor feeding, hepatomegaly, crackles, soft systolic murmur. What is the most likely diagnosis? 1. congenital infection 2. CHF 3. Sepsis

Answer 121

2. CHF

Question 122

Newborn was recently extubated after a course of systemic corticosteroids. What is the likely side effect? 1. hypotension 2. hypoglycemia 3. leucopenia 4. hypertrophic cardiomyopathy

Answer 122

4. hypertrophic cardiomyopathy - SE of steroids include HTN, hyperglycaemia, GI bleed and perforation

Question 123

A 12 hour old infant born at term had mild polyhydramnios on 20 week U/S. Now the baby is grunting intermittently with lots of secretions. He improves with intermittent suctioning. What diagnosis is this most consistent with: a. TEF/esophageal atresia b. Duodenal atresia

Answer 123

a. TEF/esophageal atresia

Question 124

Child with bubbling oral secretions, difficulties passing an NG tube. Also noted to have a hemivertebrae. What to do? a. echocardiography b. spine MRI c. MRI head

Answer 124

a. echocardiography VACTERL association - cardiac abnormalities in 50% of patients with TEF

Question 125

2-day old baby with antenatal hydro, confirmed on post-natal U/S to have moderate-severe hydronephrosis. BW shows normal renal function, baby seems to be peeing well. a. consult urology prior to discharge b. DMSA c. arrange for an outpatient VCUG d. follow up in 2 months

Answer 125

a. consult urology prior to discharge

Question 126

Newborn with persistent bradycardia. ECG given. Looks like heart block... identify the problem. What 2 things is this child at risk for?

Answer 126

1. Cardiac arrest/Death 2. Syncope 3. Dizziness 4. For infants and toddlers → night terrors, tiredness with frequent naps & irritability

Question 127

Which of the following is associated with polyhydramnios a. IUGR b. Hirschsprung’s disease c. esophageal atresia d. renal agenesis

Answer 127

c. esophageal atresia (can't swallow fluid) \*renal issues - get oligohydramnios (can't pee fluid out) \*IUGR + polyhydramnios - think trisomy 18

Question 128

What to do with a mom who is about to deliver at 23-weeks? a. resuscitation is not indicated b. all babies born \>22 completed weeks should be resuscitated c. parents ideas about resuscitation and palliation should be taken into account

Answer 128

c. parents ideas about resuscitation and palliation should be taken into account

Question 129

You are counseling a pregnant teenage girl and her boyfriend at 23 weeks gestation. She is in labour. You discuss the high morbidity at this gestational age, if the baby survives at all. What is true about the resuscitation of this newborn: a. Since they are teenagers, the physician decides. b. There is legislation in Canada that says all babies 22 weeks and older require resuscitation. c. The parents’ wishes should be supported whether they want to resuscitate or not. d. Given the high mortality at this gestation, the baby should not be resuscitated.

Answer 129

c. The parents’ wishes should be supported whether they want to resuscitate or not. 22 weeks - palliative care recommended 23-24 weeks - could go either way (parent preference) 25+ weeks - recommend early intensive care as default Above is in context of no additional risk factors (SGA, multiple gestation, no antenatal corticosteroids, delivering outside tertiary care centre)

Question 130

Expected survival rate for an infant born at 25 weeks gestation: a) \>90% b) 75% c) 50% d) 25% e) \<10%

Answer 130

b) 75%

Question 131

The outcome in neonates since the introduction of surfactant is best described as: a. decreased mortality b. decreased BPD c. increased air leaks d. increased IVH e. decreased PDA

Answer 131

a. decreased mortality \*and decreased air leaks

Question 132

Newborn baby born at 27 weeks, no spontaneous resps. What to do? a. put in polyethylene plastic bag and stimulate b. warm, dry and stimulate c. positive-pressure ventilation

Answer 132

a. put in polyethylene plastic bag and stimulate - plastic bag for all babies \<32 weeks, stimulate, if apneic then start PPV

Question 133

Newborn, a 30-week premie. Not breathing after stimulation. What do you do? a. self-inflating bag, room air b. self-inflating bag, oxygen reservoir c. self-inflating bag, oxygen reservoir with O2 being blown through d. anesthesia bag, connected to oxygen source

Answer 133

d. anesthesia bag, connected to oxygen source

Question 134

Newborn baby has copious oral secretions and respiratory distress. What is the most appropriate next test? a) Insertion of orogastric catheter b) CXR c) Abdominal U/S d) Barium swallow

Answer 134

a) Insertion of orogastric catheter - concern with lots of secretions and resp distress is TEF

Question 135

Which of the following newborns requires surfactant administration according to recent guidelines: a. Any newborn being transferred between centres b. A 29 week infant with no symptoms being transferred between centres c. A critically ill infant who has required 3 doses of surfactant in the first 18 hours d. An infant with RDS who is intubated and requiring more than 50% O2 after 72 hours

Answer 135

b. A 29 week infant with no symptoms being transferred between centres - ?best answer, none are really right - CPS: - infants delivered at \<29 weeks gestation outside tertiary care centre should be considered for immediate intubation and surfactant after stabilization NRP- prior studies suggested babies born at \<30 weeks should get prophylactic surfactant even if they weren’t intubated… now immediate use of CPAP is considered an alternative to surfactant administration

Question 136

Term male, delivered by emergency C-section for fetal distress. Meconium present, suctioned below cords. Now needing 100% O2. Radial Gas PaO2 80. Umbilical gas PaO2 40. What is the diagnosis? a) PPHN b) Meconium aspiration c) TGA

Answer 136

a) PPHN - PPHN should be suspected in all infants with cyanosis - hypoxemia is present in all cases - intermittently unresponsive to 100% O2 - oxygen saturation or PAO2 gradient between preductal (right radial artery) and post ductal (umbilical artery) sites of sampling imply shunting across PDA

Question 137

Unstable premature neonate on Ventilator with ++02 needs. Desating frequently with handling and recovering with bagging. What do you do? d) Increase sedation e) Steroids f) surfactant a) Minimize handling, increase sedation

Answer 137

a) Minimize handling, increase sedation - suspect PPHN - labile sats that recover well with bagging

Question 138

Newborn has significant respiratory distress and CXR that is consistent with pneumonia. She is ventilated with PIP 36, PEEP 5 rate 60 bpm, FiO2 1.0, she is not saturating very well. What is the likely diagnosis? What intervention should you start now?

Answer 138

1. Hypoxic Respiratory failure or PPHN 2. iNO - effective in term infants with hypoxemic resp failure

Question 139

You are taking care of a newborn ventilated baby born at 26 weeks who is now 29 weeks CGA with pulmonary interstitial emphysema on CXR. He is currently ventilated with the following settings: rate 40, PIP 18, PEEP 4, 60% O2. You receive the following blood gas: pH 7.20, pCO2 58, pO2 56, HCO3 19, base deficit -6. a. What change in ventilator settings do you make? b. 48 hours later the baby is suddenly mottled, and has the following bloodwork: Na 139, K6.8, pH 7.18, pCO2 38, pO2 68, HCO3 12, base deficit -12. The baby’s urine output is 2.5 cc/kg/hr. What complication has most likely occurred?

Answer 139

a. increase rate (best strategy for ventilation in PIE is permissive hypercapnia since escalating support can worsen PIE - increase rate over pressures to control ventilation) b. Metabolic acidosis from poor cardiac output from bad PIE or pneumothorax

Question 140

You are treating a 38 week old newborn who was flat at birth but improved with 2 minutes of PPV. Now at 12 hours of age the baby is tachypneic at 70, BP is 38/20 (mean 32). You take the following CXR. (CXR with left-sided pneumothorax, RUL collapse but no mediastinal shift) c. What is your management?

Answer 140

Needle decompression

Question 141

A newborn term infant had thin meconium at delivery but had good APGAR scores and required only 2 minutes of free flow O2. Now at 12 hours of age he has increasing work of breathing. On CXR there is hyperinflation of the RUL with mediastinal shift. What is the most likely diagnosis: a. Meconium aspiration syndrome b. Neonatal pneumonia c. CCAM d. Congenital lobar emphysema

Answer 141

d. Congenital lobar emphysema ● Congenital lobar emphysema (CLE), also known as congenital alveolar overdistension, is a developmental anomaly of the lower respiratory tract that is characterized by hyperinflation of one or more of the pulmonary lobes - intrinsic obstruction creates ball-valve mechanism

Question 142

What are 4 ways in which meconium aspiration causes respiratory problems?

Answer 142

1. inactivation of surfactant 2. airway obstruction - can lead to distal atelectasis/ball valve mechanism can lead to pneumothorax 3. reactive pneumonitis 4. pneumonia (meconium is sterile but an excellent growth medium for bacteria like e. coli, and inhibits phagocytosis by PMNs)

Question 143

16 week male born at 28 weeks GA. Hospitalized with RSV bronchiolitis. pCO2=60; pO2=94 in 50% oxygen. Chest X-ray shows RML infiltrate. Tachypneic. Best management: a. intubate and ventilate b. humidified oxygen and monitor closely c. ribavirin d. steroids e. antibiotics

Answer 143

a. intubate and ventilate - best option, IRL would probably try CPAP first

Question 144

Description of a newborn with respiratory distress. What are your 4 management options.

Answer 144

1. suction mouth and nose and ensure nares patent 2. supplemental O2 by nasal prongs 3. CPAP 4. intubate and ventilate

Question 145

Newborn term, AGA baby , cried at birth, Apgars 9 and 9. Few hours later found to be in respiratory distress. RR 80, HR high. Cap refill 4-5 seconds, BP 48/32. Hyperinflated chest with minimal indrawing. Cannot hear breath sounds on left, cannot hear heart sounds. Baby is turning cyanotic. What investigation do you do (1)? What is your possible diagnosis (1) Baby’s heart rate is now 80 and is more cyanotic. What one investigation do you want to do

Answer 145

1. transillumination 2. pneumothorax 3. needle decompression

Question 146

12h old Newborn has a sat of 80%. Increases to 85% with 100% 02. Mild tachypnea rr65. CXR has no abnormalities. What next initial management should be done? a. Intubate and ventilate b. Prostaglandins c. Antibiotics

Answer 146

b. Prostaglandins

Question 147

(CXR of a newborn with ?narrow mediastinum and ?normal pulmonary vasculature) You are asked to see a term newborn in the delivery room after an uneventful delivery and resuscitation. The baby has a RR of 70 and is cyanotic. a. What is the most likely diagnosis? b. What one treatment will you start immediately?

Answer 147

a. Cyanotic congenital heart disease (?TGA given narrow mediastinum) b. PGE

Question 148

A 3 day old is tachypneic, cyanosed despite 100% O2. Bilateral crackles on exam with weak peripheral pulses and no heart murmur. What is the diagnosis: 1. HLHS 2. Sepsis 3. AV fistula

Answer 148

1. HLHS

Question 149

Child with cyanosis, O2 sat 80% doesn’t improve with oxygen. Pan systolic murmur grade III/IV. CXR normal and ECG shows right axis deviation. What is the diagnosis?

Answer 149

?TOF

Question 150

A 3-day-old infant develops poor perfusion, diminished peripheral pulses, and decreased urine output. What medication would you administer: a) atropine b) morphine c) bicarbonate d) furosemide e) prostaglandins

Answer 150

e) prostaglandins - if antibiotics were an option that could also be a good consideration

Question 151

3 day infant cyanosis with crying, investigation a ECG b CXR c ABG d bld cx e echo

Answer 151

e echo - crying increases right sided pressure which increases right to left shunting (and therefore increases cyanosis)

Question 152

Bili question. 37 weeker. Mild lethargy. Total bili 280 @ 30 weeks (?meant hours). No ABO. Give 3 bili charts. Mgt? a. Follow-up in 24 hours b. Phototherapy and repeat bili in 6 hours c. Exchange d. IVIG

Answer 152

b. Phototherapy and repeat bili in 6 hours - medium risk line (only significant lethargy counts as a risk factor) - at/above exchange line; no use for IVIG if no ABO

Question 153

3 week old infant has jaundice. His birth weight was 3250g and he now weighs 3490g. He is breastfeeding well. Hemoglobin is 127 and total bilirubin is 270, conjugated bilirubin is 8. Coombs test is negative. What should be done? a) Admit for phototherapy b) Referral to gastroenterology c) Reassess in 1 week d) Recommend switching from breastfeeding to formula

Answer 153

c) Reassess in 1 week Breast milk jaundice

Question 154

What are risk factors for unconjugated hyperbilirubinemia in a neonate? a) Prematurity b) LGA c) male

Answer 154

a) Prematurity

Question 155

Which of the following is the best predictor of risk of Rh autoimmune hemolytic disease at the time of delivery? a. Bili in the cord b. Hb in the cord c. Mom’s Anti-Rh titres d. Gestational age

Answer 155

c. Mom’s Anti-Rh titres o Any infant of Rh-negative mom should be tested for DAT, type, Hg ▪ If DAT positive, baseline bili should be measured

Question 156

A baby has a direct hyperbilirubinemia. He was treated for an E. coli sepsis. He has hepatomegaly on exam. Which test will likely yield the diagnosis a. RBC GALT function b. G6PD level c. Osmotic Fragility d. RBC glucose-phosphate-1 deficiency

Answer 156

a. RBC GALT function Galatosemia

Question 157

You are seeing a 1 wk old Chinese boy with 1 day of jaundice. His bili is 270 (mostly indirect), Hg 95 retics 9%, Mom is AB+ and he is B+. He otherwise looks well. What is the diagnosis? a. Sepsis b. Thalassemia c. G6PD def d. ABO incompatibility

Answer 157

c. G6PD def

Question 158

Baby with bili of 280 and conjugated 200? What is the most likely cause based on incidence? a. Breastfeeding jaundice b. Hemolysis ABO c. Neonatal hepatitis d. Galactosemia

Answer 158

c. Neonatal hepatitis

Question 159

4 risk factors for increased chance of kernicterus in a baby with hyperbilirubinemia.

Answer 159

1. prematurity 2. sepsis/acidosis 3. Rh/ABO incompatibility 4. jaundice within first 24 hours of life 5. very high bilirubin level 6. asphyxia 7. G6PD deficiency

Question 160

You are called from a family doctor about a 5 day old jaundiced baby. Well looking. Total bili is 355, direct is normal. He is breastfed. What do you recommend? 1. septic work up 2. investigate for a metabolic disease 3. coombs test and hg 4. start phototherapy 5. observe

Answer 160

4. start phototherapy

Question 161

Baby with jaundice, low platelet count, looks septic. What is the cause? (Lab values given). (a) TORCH infection (b) galactosemia (c) bacterial sepsis

Answer 161

could be TORCH infection or sepsis - might lean toward sepsis since that would be worse to miss

Question 162

A 32 week gestation infant with Rh incompatibility has received 5 exchange transfusions. He now has vomiting, diarrhea, and abdominal distension. Most likely diagnosis: a) sepsis b) acute gastroenteritis c) portal vein thrombosis d) necrotizing enterocolitis

Answer 162

d) necrotizing enterocolitis - exchange transfusion or any blood transfusion is a risk factor for NEC

Question 163

3 week old who is brought to the office because mother thinks he is too yellow. Breastfed. Otherwise well. Total bili is 180. Direct is 8. What do you do? A) septic workup B) investigate for blood group incompatibility C) reassure mother that condition may last for 4-12 weeks D) investigate for metabolic disease

Answer 163

C) reassure mother that condition may last for 4-12 weeks - breastfeeding jaundice

Question 164

36 wk baby 2.1 kg (5lbs) at birth, day 7 jittery, irritable, on exam HR 218, T 37.5, RR 70 bp 90/60. Face is flushed, eyes wide open, alert but irritable, normal tone and normal cry, jaundiced, DTR's 2/4 and symmetric. There is hepatosplenomegaly. What is the likely diagnosis (1), List 2 tests to confirm your diagnosis

Answer 164

1. Likely diagnosis is congenital hyperthyroidism 2. Two tests to confirm= T4 and TSH - mom with Graves - antibodies that bind to TSH receptor in thyroid (stimulating release of T3 and T4 even though there is no TSH) cross placenta - Ix: low TSH, high T3 and T4

Question 165

33 week premature infant is born to a mother with hypertension. Baby is SGA. What other associated findings do you expect? a) polycythemia b) hyperglycemia c) hypomagnesimia d) hypercalcemia

Answer 165

a) polycythemia

Question 166

Baby with symmetric IUGR. Cause? a) smoking b) preeclampsia c) congenital infection d) placental insufficiency

Answer 166

c) congenital infection

Question 167

Baby with low apgars at birth. Picture of hypoxia. What complications would you expect over the next few days

Answer 167

Neurological - Seizures, HIE, ischemic brain injury Pulmonary - RDS, PPHN Cardiac - cardiac ischemia leading to dysfunction → muscle and conduction Renal - AKI GI - feeding intolerance, increased risk of NEC Metabolic - mitochondrial dysfunction leading to a catabolic state, decreased energy reserve Heme - thrombocytopenia, polycythemia, coagulopathies

Question 168

GBS positive mom with antibiotics given 4hrs before delivery. Would like to go home. What would be your plan? (no risk factors were given!) a. can be discharged at 48 hrs b. normal newborn care

Answer 168

b. normal newborn care

Question 169

Mom with unknown GBS. First baby. List 3 criteria for offering intrapartum abx therapy.

Answer 169

- preterm labour with imminent risk of delivery - preterm, prelabour rupture of membranes - rupture of membranes \>18 hours - intrapartum fever 38 or higher

Question 170

Mom with fever, PROM but inadequate abx therapy. Unknow GBS. Babe is born and perfectly well. Obstetrician tells you mom has chorio. What do you do: a) Cultures and abx b) CBC and observe 24 hrs c) Observe 24 hrs d) Full septic work up

Answer 170

c) Observe 24 hrs - observe for 24-48 hours - could consider CBC at 4 hours

Question 171

A newborn with 37.3 axillary temperature. What should be done next? a) Repeat after 20 minutes of unbundling b) Do a tympanic temperature c) Do CBC d) Full Septic W/U

Answer 171

a) Repeat after 20 minutes of unbundling

Question 172

Newborn with axillary temperature of 37.8 degrees, well normal exam. What do you do? a) Full septic work up and antibiotics b) Rectal temperature c) Take off all clothes for 20 minutes and recheck temperature d) CBC and diff

Answer 172

b) Rectal temperature - axillary temp recommended for screening given very small risk of perforation with rectal temp

Question 173

Mother with +ve GBS never got treated intrapartum abx. Baby born 32 wk now 9 days. Has been having increasing apneas in the past 24 h. Blood culture done shows GP cocci in clusters after 18 h of culture. What most diagnosis a. GBS b. Strep viridans c. S aureus d. Coag neg staph

Answer 173

d. Coag neg staph (clusters) - staph in cluster, strep in chains - CONS is most common cause of late onset sepsis, especially in very low BW infants

Question 174

3 week old with previous e coli sepsis and persistent jaundice. What is the likely problem. 1. Increased osmotic fragility 2. RBC galactose phosphate uradyl transferase deficiency 3. RBC glu – 1 – phosphate dehydrogenase deficiency

Answer 174

2. RBC galactose phosphate uradyl transferase deficiency - galactosemia - dx: positive reducing substances in urine (galactosuria) tx: soy formula (NO lactose)

Question 175

Pregnant mom who has a previous child. She is GBS positive, comes in at 6:00pm and gets IV penicillin. At 8:00pm, she delivers a healthy baby boy at 39 weeks. Babe is well and has a normal CBC. She is wondering when she can go home (she lives close to the hospital) a. start amp/gent b. observe until 24 hours c. observe until 48 hours d. full septic work-up

Answer 175

b. observe until 24 hours → for at least 24 h and then reassess prior to discharge.

Question 176

You are working in the NICU, and are called to see a 4 day old female born at 28 weeks. She has vomited with her last 2 NG feeds and now is noted to be distended with discoloration of the abdominal skin. You are concerned about necrotizing enterocolitis. You place the baby NPO, start antibiotic treatment and order an abdominal XR. a. Name 3 XR signs of NEC.

Answer 176

a. pneumatosis intestinalis - portal venous air - pneumoperitoneum - loss of normal bowel gas pattern (distended bowel, loss of hexagonal pattern, stacking of bowel loops) - bowel wall edema

Question 177

2 day old infant presents with fever of 39.5 ax. He is breastfed and his weight has fallen from 3.8 to 3.5 kg. He is lethargic but rouses during the examination. His fontanelle is normal. Na 150, K 7.3, Cl 110, BUN 8, Cr 110, uncong bili 190, normal CBC. What is the likely diagnosis? a) hypernatremic dehydration due to decreased fluid intake b) hypertonic breast milk c) diabetes insipidus d) sepsis e) meningitis

Answer 177

d) sepsis

Question 178

SGA prem, now 2 weeks old in NICU, baby presents with septic picture. a.) List 3 bacteria that could be responsible. b.) Initial choice of antibiotic treatment

Answer 178

a. GBS, E. coli, staph aureus, coag negative staph b. cloxacillin and tobramycin (CONS most likely), or vanco and tobra if have resistance

Question 179

Premature baby with apneas, temp instability, abdo distention with bowel loops palpable, not tolerating feeds. a.) Management/treatment x4 lines

Answer 179

a. NPO - NG to LIS - ampicillin, tobramycin, metronidazole - IV fluids/TPN - blood culture - refer to tertiary care centre with pediatric surgery

Question 180

Newborn with a TSH of 25. What do you do? a. start thyroxine b. repeat neonatal screen c. bring them into the office as soon as possible d. thyroid ultrasound

Answer 180

c. bring them into the office as soon as possible

Question 181

Term BB, mom with gestational diabetes. DOL 1. Glucose 1.4. What is your next step in management? a. Bolus glucose by NG b. Bolus 1 cc/kg of D50W c. Run IV D10 @ 80 cc/kg/day d. Frequent breastfeeding

Answer 181

c. Run IV D10 @ 80 cc/kg/day

Question 182

Male 3 weeks old. Presents with shock, hyperpigmented scrotum, low NA 115, K 6.8. What is your most important investigation? What is your immediate management?

Answer 182

Concern for CAH - ABCs - in shock therefore needs IV access and fluid bolus - hydrocortisone - Ix: 17-OHP

Question 183

3 week old has hypocalcemia. Most likely diagnosis?

Answer 183

transient hypoparathyroidism

Question 184

A 6 day old infant presents in shock with a glucose of 1.8 and cardiomegaly on CXR. Which of the following is the most likely etiology of the shock: a. Cardiac b. Sepsis c. Endocrine d. Metabolic

Answer 184

d. Metabolic - big heart? either muscle cell hypertrophy or deposition of lipids or glycogen IEMs: - amino acid: maple syrup urine disease - glycogen: hepatic glycogen storage disease - glucose: hereditary fructose intolerance - fatty acid: galactosemia, MCAD/SCAD/LCAD/VLCAD deficiency, carnitine palmitoyl transferase deficiency

Question 185

You are called to see a 2.5 kg term newborn with jitteriness. You do a bedside glucose, which is 1.7. You decided to insert an IV and give the baby a bolus of 2cc/kg of D10. a. Please write an ongoing fluid order for this baby, to be started after the bolus is complete (1 line).

Answer 185

D10W IV at TFI 80ml/kg/day

Question 186

A 2.2 kg term newborn breast feeds well at birth and then is seen at 2 hours of age with a BS of 1.9. He is asymptomatic. What is the best initial management: a. feed and recheck BS in 1 hour b. IV dextrose at 4-6 mg/kg/hr c. IV D10 2cc/kg then dextrose at 4-6 mg/kg/hr d. Supplement BF with bottle and recheck BS

Answer 186

a. feed and recheck BS in 1 hour

Question 187

Infantile cystinosis. What do you get? a. cataracts b. end stage renal failure c. nephrocalcinosis

Answer 187

c. nephrocalcinosis (the first clinical signs of infantile cystinosis appear between three and six months of age; they are largely due to impaired proximal tubular reabsorptive capacity - hypercalciuria part of this) - renal failure is later presentation if not treated - cataracts by 12-16 months

Question 188

Picture of rocker bottom feet (aka congenital vertical talus)– what condition do you need to think about?

Answer 188

T18 T13 18q deletion syndrome spina bifida, arthrogryposis

Question 189

TPN – list four metabolic complications

Answer 189

1. hypernatremia 2. TPN cholestasis 3. hypertriglyceridemia 4. hypoalbuminemia

Question 190

3 week male infant with vomiting, lethargy, decr. po intake Na 118, K 8. Most important lab test? A) vasopression B) 17OHP C) cortisol D) calcium E) renin

Answer 190

B) 17OHP

Question 191

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

Answer 191

1. GIR = 5.5mg/kg/min 2. bolus 2cc/kg of D10W IV over 5 minutes, then run D10W at TFI of 80ml/kg/day

Question 192

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

Answer 192

1. galactosemia 2. RBC GALT (galactose-1-phosphate uridyl transferase) activity

Question 193

You are discussing with a mother the prognosis of her child born at 31 weeks gestation. There was thin meconium at birth. APGARs were 8 and 9. Head ultrasound showed a small intraventricular hemorrhage at one week of age. She is concerned because he is not yet walking and has stiff legs. a) the child likely has spastic diplegia which is often associated with prematurity and intraventricular hemorrhage b) the history is unusual in that children with CP usually have a history suggestive of birth asphyxia c) IVH would cause PVL which would result in hemiplegia d) there will be progressive decline in his development

Answer 193

a) the child likely has spastic diplegia which is often associated with prematurity and intraventricular hemorrhage

Question 194

Ex-29 week prem with hyperreflexia and gross motor delay. Had history of Grade II IVH and PVL. Advise the mother about the likely cause of CP in this child. What would you see on a CT that is specific to this?

Answer 194

- IVH leading to PVL is the cause of this child's CP (PVL in prems is the most common cause of spastic diplegia) - CT would show focal areas of necrosis in the periventricular white matter

Question 195

What is the number one cause of central apnea in a 34 week prem who is now at 8 week of age? a) Seizure b) RSV c) Apnea of prematurity d) IEM

Answer 195

c) Apnea of prematurity

Question 196

Ex-30 week prem, now at 39 weeks corrected has had an uneventful course. He had apnea of prematurity treated with caffeine. He is still having apneas with occasional bradycardia 5-6 times a day. What is the likely cause? a) Apnea of prematurity b) Seizures c) GERD

Answer 196

a) Apnea of prematurity

Question 197

An ex-1500g premature infant presents with a prolonged apnea spell at 5 weeks of age. Extensive laboratory workup is unremarkable. On sending the parents home, you suggest: a. infant should always sleep on side b. infant should sleep in parents' room c. infant should sleep in own room, but parents should check on infant hourly d. an audio monitor should be placed on infant's room e. parents should not use heavy blankets in the crib

Answer 197

b. infant should sleep in parents' room

Question 198

A 4-hour-old term infant has developed tachypnea, RR 60, and has had several episodes of apnea. After initial investigations, what would you do: a) observe for further deterioration b) intubate c) antibiotics d) prostaglandins

Answer 198

c) antibiotics

Question 199

2 month old ex 32 weeker who was ventilated with Ua/Uv lines. Now has HSM but has an otherwise normal physical exam. What is the likely cause? 1. hepatic hemangioma 2. portal vein thrombosis 3. hereditary spherocytosis 4. congenital CMV 5. fungal infection

Answer 199

2. portal vein thrombosis - leading to portal hypertension

Question 200

Baby prem 33 weeks with RDS. Heart rate is 50 apneic and limp? What are your next 2 management steps?

Answer 200

1. give positive pressure ventilation with flow-inflatig bag and prepare for intubation 2. start chest compressions

Question 201

Neonate with BPD being treated with furosemide. List 4 side effects.

Answer 201

1. hyponatremia 2. hypokalemia 3. hypochloremia 4. hypercalciuria 5. nephrocalcinosis 6. dehydration

Question 202

An infant born at 26 weeks gestation is now 28 weeks (2 weeks old). He is doing well and is going to be transferred to a level II nursery. When should he be screened for ROP. a) if normal now, no need to do further follow-up b) do eye exam now c) do eye exam at 32 weeks d) do eye exam at 38 weeks e) do eye exam at 52 weeks

Answer 202

c) do eye exam at 32 weeks (technically should be 31 weeks) - if born at less than 28 weeks, screen at 31 weeks CGA, if born at 28+ weeks, screen at 4 weeks of life

Question 203

Which is an indication of seizure activity in a neonate? A. tachycardia B. abnormal eye movements C. irregular breathing D. irritability E. vomiting

Answer 203

B. abnormal eye movements

Question 204

Newborn with trisomy 21, non-bilious vomiting after feeds. What’s the test? a. Abdominal ultrasound b. Barium swallow with follow through c. Abdominal Xray d. observe for now

Answer 204

c. Abdominal Xray Usually duodenal atresia would present with bilious emesis, but initially may be non bilious and then progress to bilious - AXR shows double bubble

Question 205

Newborn diagnosed with interrupted aortic arch, what to start? a. dopamine b. prostaglandin c. nitric oxide d. indomethacin

Answer 205

b. prostaglandin

Question 206

You are called to the newborn nursery to see a 4 hour old newborn female in respiratory distress. The RR is 70 and you note increased working of breathing. The nurses have also noted that the baby has a significant amount of oral secretions. a. What one test is required to make the diagnosis?

Answer 206

a. attempt to insert NG with CXR showing NG coiled in esophagus

Question 207

What advice should you give to parents to prevent positional plagiocephaly: a. Children should be put to sleep in car seats b. Children should be put to sleep on their sides c. Children should be put on their stomachs as much as possible when awake

Answer 207

c. Children should be put on their stomachs as much as possible when awake

Question 208

Child with distress, can’t pass NG through nare. List 3 other findings on physical exam you’d look for?

Answer 208

50% associated with other anomalies; 10-20% have full CHARGE - coloboma - heart murmur - GU abnormalities - ear abnormalities - square face, arched eyebrows, prominent forehead

Question 209

Baby with constipation. Barium enema shows rectal ampulla narrow with dilated proximal bowel. a.) 2 investigations to confirm the diagnosis. b.) What would you expect as the result of each investigation.

Answer 209

- rectal biopsy: aganglionic cells - rectal manometry: failure of internal anal sphincter to relax with rectal distension

Question 210

Question where neonate has thrombocytopenia and mom’s plts are normal. Mgt?

Answer 210

Neonatal alloimmune thrombocytopenia - mgmt: platelet transfusion with maternal washed platelets or HPA1a (PLA1) negative platelets

Question 211

Description of newborn with petechiae. WBC normal, Hgb normal, plt 9. Rest of exam is normal. List 3 most likely causes aside from sepsis.

Answer 211

1. neonatal alloimmune thrombocytopenia 2. autoimmune thrombocytopenia (maternal ITP) 3. TORCH infection - congenital rubella or CMV

Question 212

Fullterm baby delivered to an O+ mom. Looks well but pale. Hb is 70, he is hemodynamically stable. What is the most likely diagnosis? 1. ABO incompatability 2. Chronic fetal maternal hemorrhage 3. Rh incompatability

Answer 212

1. ABO incompatability

Question 213

Which of the following predisposes to late hemorrhagic disease of the newborn: 1. breastfeeding 2. prematurity 3. cystic fibrosis 4. maternal phenytoin 5. oral antibiotics

Answer 213

1. breastfeeding - maternal phenytoin is a risk factor for early HDN

Question 214

Newborn with platelets of 12, transfused and post-transfusion platelets were 16. Mom’s CBC was normal. What do you do? a. transfuse single donor platelets b. transfuse PLA-1 negative platelets c. give IVIG d. give steroids

Answer 214

b. transfuse PLA-1 negative platelets (same thing as HPA-1: for alloimmune)

Question 215

Most likely cause of late hemorrhagic disease of the newborn? a. phenytoin use in mom b. baby did not get Vit K prophylaxis c. oral antibiotics d. cystic fibrosis

Answer 215

b. baby did not get Vit K prophylaxis

Question 216

Newborn with plethora and lethargy. HCR 0.72, Hb 240, Glu 3.2 on venous blood. What to do? a) Exchange transfusion b) IV D10W c) Septic workup

Answer 216

a) Exchange transfusion

Question 217

Polycythemic newborn. Hb 240, Hct 0.75. Wt 2000g. Child requires a partial exchange transfusion. What fluid do you use as the diluent? How much blood do you replace to decrease the Hct to 0.5?

Answer 217

1. NS 2. Volume = blood volume x (observed-desired hct)/observed hct = (2kg x 80ml/kg) x (0.75-0.5)/0.75 = 160ml x 0.25 / 0.75 = 40/0.75 = 53.3ml

Question 218

Baby born at home at 38 wks by midwife. Now presents at 7 days with melena. Hb 70, MCV 112, plts normal. What is the most likely diagnosis?

Answer 218

Vitamin K deficient bleeding (previously hemorrhagic disease of the newborn)

Question 219

You are called to see a 2 day old newborn male with jitteriness. At birth he was found to have a cleft palate, but has been bottle feeding well since. On physical examination, you note that the baby has a harsh systolic murmur. a. What is the most likely diagnosis? b. What is the reason for the baby’s jitteriness?

Answer 219

a. Di George b. Hypocalcemia

Question 220

Newborn is sneezing, what medication in mom could this be associated with? a. methadone b. IDM on insulin c. clindamycin

Answer 220

a. methadone

Question 221

3 day old baby with tachypnea, jitteriness, myoclonus and normal glucose. Treatment? a. Amp/gent b. Vit B c. Morphine

Answer 221

c. Morphine (NAS)

Question 222

Abstinence from methadone? Neonatal symptoms? a. Hyporeflexia b. Constipation c. Sneezing d. Lethargy

Answer 222

c. Sneezing

Question 223

Baby born to heroin addicted mom. Apneic despite bag and mask ventilation. Best management? a. Narcan b. Intubate until baby breathes on his own c. Bag and mask ventilation until baby breathes on his own

Answer 223

c. Bag and mask ventilation until baby breathes on his own

Question 224

A mother is given Demerol 90 minutes prior to delivery. The baby is suctioned and stimulated but remains apneic with a pulse of 80. Next step in management: a. bag and mask b. more stimulation c. Narcan d. Antibiotics

Answer 224

a. bag and mask

Question 225

In utero exposure to cocaine results in which of the following in the newborn: a) hearing deficits b) microcephaly c) hypotension d) spinal dysraphism

Answer 225

b) microcephaly

Question 226

What is true about neonatal chest compressions: 1. ? Required after 30 seconds of PPV with HR less than 60 2. Chest compressions to be done at a ratio of 5:1 with every breath 3. 2 finger technique is preferred 4. Required after no response to stimulation

Answer 226

1. Required after 30 seconds of PPV with HR less than 60 → there should effective ventilation PPV and an advanced airway before chest compressions

Question 227

Baby born at 41 wks. Meconium staining. Flat babe requiring resuc. Apgars 2 at 1 min 3 at 5 min and 6 at 7 min. what 5 things may you expect with this baby in the near future. What 2 tests at discharge, if normal would suggets a good neurological outcome for this child

Answer 227

1. seizures, hypotonia, hypertonia, hypotension, respiratory distress, acute tubular necrosis/AKI, GI perforation, SIADH or electrolyte abnormalities (low Na, Ca, hypoglycemia), DIC 2. Good neuro outcome: normal EEG and MRI

Question 228

Newborn with an Erb’s palsy. Which is true? a. extension at the wrist b. preserved grasp c. symmetric moro

Answer 228

b. preserved grasp

Question 229

Baby with renal mass and hematuria. Most likely associated with? a. IDM b. polycythemia c. dehydration d. UVC

Answer 229

a. IDM Presentation of RVT: Sudden onset gross hematuria (can also be microscopic), Unilateral or bilateral flank masses, Hypertension, Oliguria - perinatal risk factors including asphyxia present in 31% of cases - maternal diabetes in 8% - dehydration in 1.5% - polycythemia not mentioned

Question 230

Antenatal U/S shows moderate hydro. U/S at 24 hrs normal. What to do next and why.

Answer 230

repeat U/S after first 3 days of life, as can have false negative results prior to this while baby still digressing

Question 231

Description of child with prune belly. Weak abdominal musculature. Cryptocidism. Baby in intubated in NICU. Bilateral abdominal masses on exam. What is this associated with. a) Bilateral wilms b) Polycystic kidneys c) Multicystic kidneys d) Hydronephrosis

Answer 231

d) Hydronephrosis

Question 232

List 4 non-infectious risk factors of hearing loss in the newborn period.

Answer 232

1. hyperbilirubinemia 2. anatomic ear abnormalities (atresia or stenosis of ear canal) 3. ototoxic medications (aminoglycosides, loop diuretics) 4. family history of childhood SNHL 5. mechanical ventilation \>5 days 6. BW \<1500g 7. apgars \<5 at 1 minute, \<7 at 5 minutes

Question 233

4 biologic determinants of child development.

Answer 233

1. genetics 2. in utero exposure to teratogens 3. low birth weight 4. post natal illness 5. prematurity 6. exposure to toxic/hazardous substances