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September Board Review

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1 September Board Review
Fetus and Newborn

2 Care of the Well newborn

3 Prenatal Visit Most important focus: begin a positive relationship with the parents!! History Mother’s medical and pregnancy history Depression Medications Use of tobacco/ other substances Maternal and paternal family history Social History Support system

4 Prenatal Visit Feeding plan Anticipatory guidance
BF (encourage!!) Anticipatory guidance Routine office procedures

5 Antenatal US Findings Choroid plexus cysts
Seen commonly prior to 24 wga If not associated with other anomalies, unlikely to be of any significance No need for follow-up Echogenic intracardiac focus Bright spot near the papillary muscle of left ventricle May be associated with Trisomy 21 Is a normal finding in most cases

6 Antenatal US Findings Echogenic bowel
?Marker for: Aneuploidy CF Congenital Infections Rare intestinal d/o Most infants normal Mild enlargement/ asymmetry of the cerebral ventricles Cranial US after delivery appropriate Echogenic bowel: With this finding on antenatal US, fetus will likely undergo karyotype, CF and CMV testing before delivery If all negative and infant’s PE normal on delivery, no FU needed Enlarged ventricles serial US, karyotype, CMV and Toxo testing before delivery

7 Antenatal US Findings Hydronephrosis
If pelvic dilatation >4mm in second trimester, or >7mm in the third trimester postnatal US If caliectasis (dilation of the calyces) seen, do US even if hydronephrosis doesn’t meet size requirements VCUG 10-30% of newborns with antenatal hydronephrosis have VUR

8 Delivery 10% of infants require some form of resuscitation
20% of those infants require aggressive intervention Most infants establish regular respirations at 1 min of age

9 Delivery Minimize heat loss!
At risk due to large area-to-body mass ratio Cold stress depletion of fat and glycogen Healthy infants: Dry Swaddle with dry linen Skin-to-skin contact with Mom Sick Infants Radiant warmer *Weighing/measuring, erythromycin, and Vit K can be delayed for 1 hour to allow for skin-to-skin and to encourage latch-on for BF during baby’s early alert period

10 Question #1 A 37 wga M was born via C-section for failure to progress. His Apgars were 9 and 9 at 1 and 5 minutes. The significance of his one and five minute Apgar scores is: A. He tolerated the delivery process well, but his transition has not been successful B. He did not tolerate the delivery process well, but his transition has been successful C. He tolerated the delivery process well, and his transition has been successful D. He did not tolerate the delivery process well, and his transition has not been successful E. He is alive Apgars< 7 at risk for suboptimal transition, require close observation Apgars< 3  ?NICU

11 Apgar Scoring Sign 1 2 Heart Rate Absent Under 100 bpm Over 100 bpm
1 2 Heart Rate Absent Under 100 bpm Over 100 bpm Color Blue/pale Pink body, blue ext All pink Respiratory Effort Slow (irregular) Good crying Muscle Tone Limp Some flexion of ext Active motion Reflex Irritability No response Grimace Cough or sneeze

12 After Delivery Frequent VS in the first hours after birth
Frequent BPs not necessary Identify infants at risk for specific problems: Infection Hypoglycemia HIV Hepatitis B Effects from maternal medications Vitamin K and erythromycin

13 After Delivery First Feedings
Formula should be avoided in absence of medical indication Sterile water/ glucose water should be avoided

14 First Exam Estimated gestational age Growth Parameters (plot them!)
Definitions Preterm: <37 wga Term: Between 37 and 41 6/7 wga Postterm: >42 wga Growth Parameters (plot them!) Birthweight <10th percentile: SGA Problematic transition Poor feeding Hypothermia Hypovolemia Hypoglycemia SGA at risk for problems related to poor reserve and increased metabolic requirements

15 First Exam Growth Parameters (con’t)
Birthweight >90th percentile: LGA Hypoglycemia Birth Trauma Clavicular fracture Scalp hematoma Brachial plexus injury IUGR: baby that does not follow the expected prenatal growth pattern Low birth weight: <2500g

16 First Exam Weight loss Healthy infants may loose 2-3% of BW for the first 2-3 postnatal days When BF is optimal, weight loss begins to plateau after 48-72h Weight loss >7-8% should be evaluated

17 Question #2 All of the following are physical characteristics of a post-term infant EXCEPT: A. Dry/peeling skin B. Sparse hair C. Decreased subcutaneous tissue D. Wrinkled skin E. Abundant vernix

18 First Exam Consider doing at bedside with parents present Confirm EGA
Can assess the quality of the infant-parent interaction Confirm EGA Preterm Infants Abundant vernix Decreased subcutaneous fat Pink, thin skin Decreased tone Immature reflexes

19 First Exam Confirm EGA (con’t) Term Infant Post-term Infant
Pink and chubby Alert, able to fixate visually Normal muscle tone and reflexes Post-term Infant Decreased subcutaneous tissue Dry or peeling skin Wrinkled skin or sparse hair

20

21 First Exam Important components of the PE: Red Reflex Palate
Calm assessment of: Heart Lungs Abdomen Hips

22 Question #3 All of the following are issues encountered by near-term infants ( /7 wga) EXCEPT: A. Hypothermia B. Decreased daily fluid requirement C. Breastfeeding problems D. Increased insensible water loss E. Increased rate of readmission

23 Care of Near-Term Infants
Near-Term Infants at risk for: Hypothermia Hypoglycemia Jaundice/ kernicterus Breastfeeding problems/ dehydration Increased rate of readmission Greater daily fluid and calorie/kg requirement Increased insensible water losses Prematurity Radiant warmer Phototherapy

24 Care of Near-Term Infants
Remember a car seat test in infants <37wks (1-2 h observation of HR, RR and O2 while in the car seat)

25 Breastfeeding Recommend human milk for all infants except where contraindicated

26 Breastfeeding Educate and support both parents
Put healthy infants skin-to-skin until first feeding accomplished Avoid procedures that may interfere Avoid glucose water or formula supplements Avoid pacifiers during initiation Feed on infant demand (at least 8-12 times/d) Formal evaluation twice daily while in the hospital

27 Breastfeeding Close f/u after hospital d/c
Encourage exclusive BF for 6 months Have mother and infant sleep in close proximity Should either Mom or baby need hospitalization, make every effort to maintain BF or provide human milk for the infant

28 Routine Screening and Testing
Blood glucose Infants at risk for hypoglycemia IDM LBW (<2500g) SGA or LGA Hypothermia Signs of hypoglycemia or sepsis Hearing screening OAE BAER 1-3/1000 infants have bilateral hearing loss

29 Routine Screening and Testing
Newborn metabolic/genetic screening Hepatitis B prevention Vaccination for everyone! HBIG (in addition to vaccine) to infants born to mothers HbSAg+ Syphilis More info to come later!

30 Routine Screening and Testing
Group B Strep All women should be screened at wks Prophylaxis indicated with: Previous infant with invasive GBS GBS bacteruria during the current pregnancy Positive GBS screen during the current pregnancy Unknown GBS status AND: Gestation <37 wks ROM> 18h Intrapartum fever >38.0

31 Fig 3.5. Empiric management of a neonate whose mother received intrapartum antimicrobial prophylaxis (IAP) for prevention of early-onset group B streptococcal (GBS) diseasea or suspected chorioamnionitis. Red Book Online Visual Library, Image FIGURE3E. Available at: Copyright ©2009 American Academy of Pediatrics

32 Question #4 You are examining a 24h old female in the room with Mom and Dad. When you begin to examine her hips, Mom mentions that her first child had a hip problem that required a harness. On your exam, both the Barlow and Ortolani are negative. She asks if any testing will need to be done for this baby to make sure her hips are normal. Your answer is: A. No, since her physical exam is normal, no further testing is needed B. You will see her weekly for the next 4-6 weeks to check her hips, and if her exam becomes abnormal x-rays will be done C. Yes, you will do pelvic x-rays before the infant is discharged D. No, there is no significance in the positive family history E. Yes, a screening hip US will be done at 4-6 wks of age

33 Common Problems Hyperbilirubinemia Developmental dysplasia of the hip
Positive Barlow or Ortolani Ortho referral Equivocal signs re-examine in 2 weeks and refer if signs persist Those with risk factors: Hip US at 4-6wks Breech presentation Positive FHx

34 Common Problems Delayed voiding or stooling

35 Anticipatory Guidance
Back to sleep “Tummy time” as much as possible while baby is awake to help with positional plagiocephaly Car seat Appropriate fit and position in the car Hands-on teaching Car seat testing for infants <37 wks Umbilical cord care Dry cord care

36 Discharge Normal discharge criteria
48h after a vaginal delivery and 72-96h after CS Medical readiness: Stable VS x12h Normal PE, well-appearing Voided and stooled Feeding well Completed all screening tests Appropriate F/U scheduled Parent education completed and competency demonstrated

37 Early Discharge Criteria for early discharge (<48h)
After vaginal delivery only Antepartum, delivery, and postpartum course uncomplicated for mother and baby Term baby, appropriate for gestational age Evaluation for jaundice completed Prompt outpatient F/U arranged

38 Early Discharge Benefits Complications Improved bonding and attachment
Minimization of iatrogenic risks Complications Delayed detection of treatable medical conditions Hyperbilirubinemia Poor feeding/ early termination of BF Hospital readmission

39 First Outpatient Visit
Several days (not 2 weeks) after D/C Weight? Should not have lost more than 7-8% of BW Feeding? Volume/duration, frequency, spit-ups? Voiding? 6-8 voids Yellow, seedy stools daily Sleeping? Back to sleep Concerns? Post-partum depression…watch mom/dad’s interaction with the infant

40 Newborn Resuscitation

41 Newborn Resuscitation
Achieving a stable airway, ventilation, and oxygenation are the first and most important steps

42 Airway, Ventilation, Oxygenation
A normal newborn infant has established regular respirations by 1 minute of age Bag-valve-mask ventilation can be difficult due to poor lung compliance and fluid-filled alveoli Increased positive pressure is necessary (especially for the first breath) Recent recommendations are to use 100% oxygen during PPV, monitor arterial sats, and decrease concentration as soon as possible

43 Question #5 You are attending the birth of a 36 WGA male, who was just delivered via C-section. After being warmed with blankets and stimulated, you notice his color is blue and he is not taking effective respirations. You begin positive pressure ventilation via bag-mask with 21% O2, and ask for a pulse ox reading. After getting good chest rise and hearing adequate breath sounds throughout, the pulse ox reads SaO2 89% and HR of 45. Of the following, the next BEST step in resuscitation is: Intubate immediately and begin mechanical ventilation Give Epinephrine Chest compressions Intubate immediately and give surfactant via ETT Give Dopamine

44 External Cardiac Massage
Adequate ventilation is usually sufficient to reverse bradycardia Compressions should be initiated if the infant’s heart rate remains less than 60 beats/min Should be directed above the xiphoid process Depress chest 1/3 AP diameter Recommended ratio is 3 compressions to 1 ventilation at a rate of 100 compressions per minute

45 External Cardiac Massage
Encircle the infant’s chest with 2 hands and depress the sternum with both thumbs Chest compressions decrease tissue damage from cardiac arrest by providing cardiac output to vital organs

46 Metabolic Consequences
Endothelial cell damage → release of von Willebrand factor and tissue thromboplastin → activates a procoagulant state →microthrombosis and tissue ischemia Free radical release Arachindonic acid cascade activation Excessive neurotransmitter release Mitochondrial damage Neutrophil activation Cell apoptosis Inflammatory cascades Of cardiac arrest/poor perfusion

47 Question #6 The use of hypothermia is recommended as effective treatment for asphyxia-related brain injuries. True False

48 Return of Circulation Management of multiorgan dysfunction
Maintain adequate blood pressure, cerebral perfusion pressure and cardiac function Closely monitor body temperature Avoid hyper- or hypothermia Minimize heat loss by wrapping the baby

49 Meconium Aspiration In addition to nasopharyngeal suctioning, a newborn infant’s larynx needs to be visualized and the trachea suctioned if thick or particulate meconium is present in the amniotic fluid and the infant is not vigorous

50 Very-low-birth weight infant

51 Resuscitation Check to ensure all necessary equipment is available:
-Warmer -Blankets -Suction -Laryngoscope -ETT (appropriate size) <28 weeks (<1000 g): 2.5 mm 28-34 wks( grams): 3.0 mm weeks ( grams): 3.5 mm >38 weeks (>3000 grams): 3.5 to 4.0 mm -UVC/UAC supplies -Meds for resuscitation -Oxygen -Pulse ox

52 Thermoneutral Environment
Core body temp decreases rapidly from heat loss after delivery Hypothermia is assoc. with adverse outcomes Goal is to keep body temp 97.7 to 98.6°F Keep delivery room 77 to 80.6°F Place infant on radiant warmer Wrap in prewarmed blankets Place baby in polyethylene bag immediately after delivery before drying Once in NICU care for on radiant warmer or isolette Monitor temp with probe

53 APGAR Scores Difficult in VLBW infant Tone and reflexes are diminished
Often cannot achieve an Apgar greater than 6 because of neurologic immaturity Hypotonia Blunted response to noxious stimuli

54 Question #7 A 28 WGA male infant was just delivered via C-section. He weights 1000g. He is intubated in the delivery room due to respiratory distress, and has UAC and UVCs placed. He is stabilized, and upon arrival to NICU, his nurse asks if you want to start IVFs. Of the following, the MOST appropriate initial solution for parenteral administration is: 5% dextrose 5% dextrose and 0.2% sodium chloride 10% dextrose 10% dextrose and 0.2% sodium chloride 0.9% sodium chloride

55 Blood Glucose Obtain blood glucose measurement as part of initial assessment Preterm infants have low endogenous glycogen and fat stores and a relatively limited capacity for gluconeogenesis Require a continuous infusion of glucose to prevent hypoglycemia Initial requirement is 4 to 6 mg/kg/min (GIR) Provided as 10% dextrose at a rate of 80 to 120 ml/kg/day BG should be >50 in first 24 hours, and >50 to 60 thereafter

56 Blood Glucose At 1 week after birth total fluid is 130 to 170 ml/kg/day GIR of 8 mg/kg/min provides adequate carbohydrate nutrition while maintaining appropriate blood glucose in a baby not being fed Some develop hyperglycemia on lower glucose infusion rates and require lower concentrations of dextrose (7.5 or 5%)

57 Nutrition VLBW infants develop significant protein deficits in first week Start TPN with at least 1.5 g/kg/d of amino acids 40 cal/kg from carbohydrate and fat Early feeds with human milk have shown to improve survival Promote intestinal growth Reduce risk for late-onset sepsis and NEC Improve neurodevelopmental outcome Requires nutrient fortification Nutrient fortification to prevent macronutrient and mineral deficiencies that contribute to suboptimal extrauterine growth and osteopenia

58 Respiratory Distress RDS caused by lung immaturity and surfactant deficiency is common in VLBW Pulse ox and arterial blood gas analysis can minimize episodes of hyperoxia and hypocarbia Give supplemental oxygen to keep PaO2 between 50 and 70 mmHg and sats between 85-95% CPAP and intubation with surfactant administration when appropriate → as soon as possible

59 Sepsis Unless there is a clear noninfectious cause for the preterm delivery, the infant should be evaluated for infection and treated with abx CBC, blood cx, and CRP Broad-spectrum abx: Amp and Gent To cover most common pathogen: GBS, Listeria, E. coli Infants who’s mom’s received abx have a greater risk of infection with gram-negatives If suspect HSV (vesicular rash, thrombocytopenia, seizures) CSF and surface cultures, PCR Start Acyclovir Maternal infection is a common trigger for preterm labor and delivery

60 Question #8 You are seeing a 2 ½ month-old female in clinic for a well-check. The patient is an ex-premie born at 27 weeks and had a NICU course complicated by NEC requiring surgery to remove part of her small intestine. Since discharge from the NICU, she has been doing well, tolerating feedings and gaining weight. Her mom asks you about her development and if she will be normal. Of the following, which is NOT a factor associated with high risk for adverse neurodevelopmental outcome: Female sex Gestational age less than 28 weeks NEC Need for surgery Cerebral white matter injury

61 Neurodevelopmental Outcome
15 to 20% of VLBW infants develop an intracranial hemorrhage Grade I IVH (subependymal or periventricular hemorrhage) → do not have a significantly increased risk of adverse neurodev. Outcome Grade II IVH (bleeding into the ventricle without dilatation) → a small increase in adverse neurodev. outcome (academics, memory, executive function)

62 Neurodevelopmental Outcome
Grade III IVH (bleeding into ventricle with dilatation) → 30% have neurodev. Impairment Grade IV IVH (intraventricular and intraparenchymal bleeding) → 90% have neurocognitive or motor impairment

63 Neurodevelopmental Outcome
Highest risk for adverse outcomes: Male <28 weeks BPD Cerebral white matter injury Late onset sepsis NEC Need for surgery Poor weight gain or head growth

64 Neonatal jaundice

65 Bilirubin Metabolism Conjugation reaction is catalyzed by UGT-1A1
Then excreted into bile and the gut In the newborn, much of the conjugated bili in the intestine is hydrolyzed back to unconjugated bili Then reabsorbed into the blood stream by enterohepatic circulation Catabolism of heme Unconjugated bili is released into circulation where it is reversibly but tightly bound to albumin

66

67 Breastfeeding and Jaundice
A strong association between breastfeeding and hyperbili Breastfeeding jaundice In the first 2 to 4 postnatal days Related to increase in enterohepatic circulation stimulated by fewer calories received until milk “comes in” Human milk jaundice syndrome Appears later (onset at 4 to 7 days) Gilbert syndrome Increased incidence in prolonged hyperbilirubinemia beyond 2 to 3 weeks

68 Pathologic Causes of Jaundice

69 ABO Hemolytic Disease Baby = A or B Mom = O
1/3 of these infants have a positive Coombs or DAT test Twice as likely to have moderate hyperbilirubinemia, but sever jaundice is uncommon Common in the first 24 hours

70 G-6PD Deficiency Most common and clinically significant red cell enzyme defect 11 to 13% of African-American newborns 30% of infants with kernicterus found to be deficient Gene is on X chromosome Hemizygous males = full enzyme deficiency Heterozygous females = also at risk

71 Question #9 You get a call from the newborn nursery that a baby has just been delivered. The infant is a healthy 37 WGA African-American male, and mom plans to breastfeed. Of the following, which is associated with DECREASED risk of significant jaundice: His brother received phototherapy as an infant African-American race He has a cephalohematoma on physical exam Gestational age of 37 weeks Male sex

72

73

74

75 Question #10 You are about to discharge a 48 hour old full-term male infant born via uncomplicated vaginal delivery. At 40 hours old, his total serum bilirubin was 9 mg/dl. On physical exam he is jaundiced in the face. He is successfully breastfeeding, and he has the same blood type as mom. Of the following, the next BEST step in managing is jaundice is: A. Schedule follow-up for 1 week B. Obtain CBC with retic C. Schedule follow-up appointment within 48 hours D. Start phototherapy E. Repeat total serum bilirubin

76 Follow-up The AAP now recommends that any infant discharged at less than 72 hours of age should be seen within 2 days of discharge Most infants delivered vaginally leave the hospital before 48 hours, so bilirubin peaks after discharge (peak = 3 to 5 days) It is essential that total serum bilirubin values be interpreted in terms of the infant’s age in hours not days

77 Big difference between 24 hours and 47 hours

78

79 When to Seek a Cause Cause is often apparent from history and physical
If total bili is above 95th percentile or rising rapidly and crossing percentiles Blood type and Coombs CBC, retic Direct bili Consider G-6PD If elevated direct bili → UA, urine cx, evaluate for sepsis

80 Visual Assessment of Jaundice
Visual diagnosis is unreliable, especially in dark skinned infants The difference b/w a TSB of 5 and 8 cannot be detected with the eye, but represents a difference b/w the 50th and 90th percentile Some experts recommend screening all newborns with a TSB or TcB Some recommend getting a TSB when TcB is >75th percentile

81 Question # 11 You see a 4-day-old (96 hours) female in clinic for follow-up of hyperbilirubinemia. She was born at 36 WGA and has been breastfeeding well. Both of her older sisters required phototherapy as infants. You repeat total serum bilirubin today and the value is 16 mg/dl. Of the following, the next BEST step is: Admit to the hospital for exchange transfusion Instruct mom to breastfeed every 4 to 6 hours Start Phenobarbital Admit to the hospital for phototherapy Start home phototherapy

82 Treatment 1) Exchange transfusion to remove bili mechanically
2) Phototherapy to convert bili to products that can bypass the liver’s conjugating system and then be excreted in bile or urine 3) Pharmacologic agents

83 Phototherapy Photons are absorbed by bili in the skin
Undergoes photochemical reaction to form excretable isomers Most effective light is in the blue-green spectrum When applied appropriately, expect a 30 to 40% decrease in bili in the first 24 hours (most significant decline happens in 4 to 6 hours) Home phototherapy should not be used in infants with risk factors

84 Our second favorite nomogram
Similar one for exchange therapy

85 Pharmacologic Therapy
Phenobarbital Ursodeoxycholic acid Tin mesoporphorin

86 Newborn respiratory disorders

87 Presentation of Respiratory Distress
Tachypnea RR>60 Grunting Produces elevated transpulmonary pressures maintenance of FRC Seen in disease states where alveoli are prone to collapse (RDS) Nasal flaring Reduction in nasal resistance reduction in total lung resistance Retractions (intercostal, subcostal, suprasternal) Become more apparent as the lung becomes less compliant (RDS) Central cyanosis Advanced sign of respiratory distress Less clinically apparent when the patient is anemic

88

89 Assessment First thing’s first: ABCs!! Physical Exam Stabilize per NRP
Temperature instability infection Tachycardia infection, hypovolemia Scaphoid abdomen CDH Asymmetric chest wall movement tension PTX Asymmetric breath sounds PTX Stridor UA obstruction

90 Assessment Initial labs/ radiology CXR Glucose ABG CBC with diff BCx

91 Assessment History Maternal Pregnancy DM? Medications? Polyhydramnios?
TEF Oligohydramnios? Pulmonary hypoplasia Triple Screen Genetic defects Prenatal US BPP (fetal heart rate, muscle tone, movement, breathing, and amniotic fluid index) DM hypoglycemia, relative surfactant deficiency, polycythemia

92 Assessment History (con’t) Labor and delivery History of presentation
Fetal monitoring? Complications? Placenta previa/ abruption Presence of meconium? History of presentation Initial respiratory distress that improves with minimal intervention TTN Gradual deterioration PNA, RDS, sepsis TTN=RFLLS (retained fetal lung liquid syndrome)

93 Differential Diagnosis
Pulmonary causes RFLLS (TTN) RDS Meconium aspiration syndrome PNA Non-pulmonary causes Cardiac disease Infection Metabolic d/o CNS d/o

94 Question #12 A 3260g term male infant was born via spontaneous vaginal delivery. There was an prolapsed umbilical cord during delivery, but the infant emerged vigorous and pink. Maternal history was negative with the exception of some analgesia needed during labor. You were called right after the infant arrived in the nursery, because he was tachypenic with some nasal flaring and retractions. All the following details of the history are consistent with diagnosis of transient tachypnea of the newborn (or RFLLS) EXCEPT: A. Male infant B. Vaginal delivery C. Umbilical cord prolapse D. Maternal analgesia during labor E. Respiratory distress presenting immediately after birth

95 TTN (RFLLS) Pathophysiology:
Transient pulmonary edema resulting from delayed clearance of fetal lung fluid During pregnancy, lung epithelium primarily a secretory membrane 2-3 days prior to onset of labor, epithelium becomes an absorbing membrane 40% of lung fluid is absorbed before a spontaneous vaginal delivery Rest of fluid must clear within hours of birth for successful transition to occur

96 TTN (RFLLS) Risk factors Male sex C-section delivery
Perinatal asphyxia Umbilcial cord prolapse Maternal complications Asthma Diabetes Need for analgesia/ anesthesia during labor

97 TTN (RFLLS) Occurs in per 1000 term infants and 10 per 1000 preterm infants Presentation (immedately after birth) Tachypnea Grunting Nasal flaring

98 TTN (RFLLS) Diagnosis Resolution of Sx 1-5d after minimal therapeutic
Intervention CXR Prominent perihilar streaking Increased interstitial markings Fluid in the interlobar fissures Diffuse involvment which makes RFLLS difficult to distinguish from RDS; irregular opacifications may cause RFLLS appear more like MAS

99 TTN (RFLLS) Treatment Prognosis Supportive
Oxygen (at times, high concentrations) CPAP Helps with the absorption of the fluid (Rarely) mechanical ventilation Prognosis Benign and self-limited disease No long-term sequelae

100 Question #13 A 30 wga male is born via SVD. Immediately after birth, he has signs of respiratory distress. CXR shows diffuse microatelectasis, diminished lung volume, and air bronchograms. The underlying pathophysiology of this infant’s illness is: A. Meconium aspiration B. GBS infection C. Retained fetal lung fluid D. Surfactant deficiency E. Airway hyperreactivity

101 Respiratory Distress Syndrome (RDS)
Pathophysiology Surfactant deficiency Mixture of lipids and proteins Produced by type II pneumocytes Absence increased surface tension and alveolar collapse Risk Factors Prematurity!!! 60% of babies born at <28wks 30% of babies born at <30wks <5% of term babies

102 RDS Risk Factors (con’t) Male sex Maternal gestational diabetes
Perinatal asphyxia Hypothermia Multiple gestations

103 RDS CXR Diffuse microatelectasis ”ground glass” appearance
Overall diminished lung volume Air bronchograms

104 RDS Treatment Antenatal Postnatal
Administration of corticosteroids to women at risk for preterm labor before 34 wga Reduces risk of RDS by accelerating fetal lung maturation Postnatal Surfactant replacement Intubation surfactant administration immediate extubation becoming more popular Nasal CPAP or mechanical ventilation

105 RDS Complications (associated with Rx for RDS)
Bronchopulmonary dysplasia (BPD) Supplemental oxygen needed at 36 wks corrected gestational age Results from high levels of oxygen administration and mechanical ventilation

106 Question #14 A 41 wga F is transferred to the NICU 12h after delivery for worsening respiratory distress. Pregnancy and delivery were unremarkable, except for moderately meconium-stained amniotic fluid. She decompensates and requires intubation and mechanical ventilation after her arrival to the NICU. You suspect meconium aspiration syndrome (MAS). All of the following have been proven efficacious interventions for MAS EXCEPT: A. Amnioinfusion B. Inhaled NO C. ECMO D. Surfactant therapy E. Mechanical ventilation

107 Meconium Aspiration Syndrome (MAS)
Definition Respiratory distress in an infant born through meconium-stained amniotic fluid whose symptoms cannot be otherwise explained 13% of deliveries with meconium-stained fluid 4-5% develop MAS Pathophysiology Increased fetal stress relaxation of the anal sphincter passage of meconium in utero Chronic fetal hypoxia and acidosis gasping aspiration of meconium severe MAS Increased fetal stress: maternal HTN, maternal diabetes, eclampsia

108 MAS Pathophysiology (con’t)
Severe MAS remodeling and thickening of the pulmonary vessels pulmonary vascular hyperreactivity, vasoconstriction, and HTN Meconium also directly toxic to the lungs (bile salts and pancreatic enzymes) Causes chemical pneumonitis Inactivates surfactant Activates complement Thick meconium itself causes airway obstruction

109 MAS Presentation First 12h after birth
Varying degrees of respiratory distress Barrel chests, crackles and rhonchi on exam

110 MAS Patchy atelectasis Overinflation Widespread involvement
Complete airway obst Overinflation Air trapping with partial airway obst Widespread involvement Most severe cases white out Extreme overinflation air leaks Air leaks: PTX, pneumomediastinum, and PIE

111 Treatment Good oxygenation Surfactant replacement Inhaled NO
Hypoxemia increased pulmonary vascular resistance worsening of PHTN Surfactant replacement Inhaled NO High frequency ventilation No RCT have compared conventional to HFOV ECMO For pts who fail iNO therapy Survival rate of % Surfactant replacement decreased need for ECMO and decreased incidence of PTX iNO pulmonary vasoldilation decreased VQ mismatchdecreased need for ECMO

112 Question #15 An 39 wga F is transferred to the NICU at 6h of age after a prolonged apneic episode. She was also noted to be lethargic and feeding poorly. Her PE is significant for some crackles at the RUL. Pulses are 2+ throughout and CRT< 2sec. CXR obtained on admit is shown. Appropriate treatment for this illness would include: A. Supportive care B. Surfactant administration C. Intubation and suctioning of the trachea D. IV Ampicillin and Gentamicin E. ECMO

113 Pneumonia Most common infection in the neonate May develop:
Antenatally: Rubella HSV CMV Adenovirus Toxoplasma Varicella

114 Pneumonia May develop (con’t): Perinatally Post-natally GBS E.Coli
Klebsiella Chlamydia trachomatis Post-natally RSV Gram-positive bacteria Gram-negative bacteria

115 Pneumonia Presentation Signs typically present at birth
Respiratory distress Lethargy Poor feeding Jaundice Apnea Temperature instability

116 Pneumonia CXR Appearance depends on the cause: Pleural effusion
In utero infection bilateral “white out” GBS PNA can be indistinguishable from RDS or RFLLS Pleural effusion Mild cardiac enlargement 50% of pts with PNA have indistinguishable x-rays from RDS and RFLLS

117 Pneumonia Additional work-up Treatment CBC with diff BCx Antibiotics
Before ABx therapy started Treatment Antibiotics Ampicillin and Gentamicin Supportive therapy Oxygen Mechanical ventilation Vasopressor support

118

119 Neonatal infections

120 Toxoplasma Gondii Oocytes shed in cat feces In Mom Transmission:
Mono-like illness LAD Transmission: Early in pregnancy: lower chance of fetal infection but consequences of infection are more severe Later in pregnancy: greater chance of fetal infection but with less severe sequelae

121 Toxoplasma Gondii Presentation (vast majority asymptomatic in the newborn period) Microcephaly Hydrocephaly Chorioretinitis Diffuse cerebral calicifications Jaundice HSM Presentation very similar to CMV!!! Later signs: deafness, impaired vision, szs, MR, learning disabilities, cognitive defecits

122 Image 139_28. Toxoplasma gondii Infections (Toxoplasmosis) A white male neonate with congenital toxoplasmosis with petchiae, hepatosplenomegaly, and micropenis. Red Book Online Visual Library, Image 139_28. Available at: Copyright ©2009 American Academy of Pediatrics

123 Image 139_04. Toxoplasma gondii Infections (Toxoplasmosis) T gondii retinitis. Note well-defined areas of choroidoretinitis with pigmentation and irregular scarring. Red Book Online Visual Library, Image 139_04. Available at: Copyright ©2009 American Academy of Pediatrics

124 Image 139_27. Toxoplasma gondii Infections (Toxoplasmosis) A CT scan of an infant with congenital toxoplasmosis demonstrating multiple intracranial calcifications. Remember: Calcifications in CMV “circumvent: the ventricles, they are diffuse in Toxo Red Book Online Visual Library, Image 139_27. Available at: Copyright ©2009 American Academy of Pediatrics

125 Toxoplasma Gondii Diagnosis Treatment Toxoplasma IgM (IgG)
Pyrimethamine Sulfadiazine Leucovorin

126 Rubella Person-to-person transmission by droplets In Mom
Posterior auricular LAD Rash Low-grade fever Polyarthralgia/ arthritis Fetal transmission 1st trimester: high likelihood of infection (90%) with serious sequalae 3rd trimester: infection risk % but non-teratogenic

127 Rubella Presentation Diagnosis Treatment
Thrombocytopenic purpura (“blueberry muffin” lesions) Radiolucencies in the metaphyseal long bones Congenital heart disease PDA +/-PPS or ASD/VSD Sensorineural deafness Cataracts/ glaucoma Diagnosis Rubella IgM (acute and convolescent IgG) Treatment Supportive

128 Image 115_14. Rubella Newborn with congenital rubella rash.
Red Book Online Visual Library, Image 115_14. Available at: Copyright ©2009 American Academy of Pediatrics

129 Image 115_16. Rubella This photograph shows the cataracts in an infant's eyes due to Congenital Rubella Syndrome. Rubella is a viral disease that can affect susceptible persons of any age. Although generally a mild rash, if contracted in early pregnancy, there can be a high rate of fetal wastage or birth defects, known as Congenital Rubella Syndrome (CRS). Red Book Online Visual Library, Image 115_16. Available at: Copyright ©2009 American Academy of Pediatrics

130 Image 115_08. Rubella Radiolucent changes in the metaphyses of the long bones of the upper extremity of an infant with congenital rubella. Red Book Online Visual Library, Image 115_08. Available at: Copyright ©2009 American Academy of Pediatrics

131 CMV Transmission through contact with infected blood, urine, respiratory secretions In Mom Mono-like illness Fever, malaise, mild hepatitis Fetal transmission In utero (most severe) During delivery Neonatal period (breastmilk, blood transfusion) Whether or not the infant will be infected in utero is largely dependent on if mom has IgG Ab to CMV (which greatly decreases the chance of infection and the severity of the infection)

132 CMV Presentation (cytomegalic inclusion disease) IUGR HSM/ jaunice
Thrombocytopenia “Blueberry muffin” rash Microcephaly Chorioretinitis Sensorineural hearing loss Periventricular cerebral calcifications Later symptoms: hearing loss, growth retardation, MR

133 Image 039_22. Cytomegalovirus Infection This is the same infant as in image 039_21.
Red Book Online Visual Library, Image 039_22. Available at: Copyright ©2009 American Academy of Pediatrics

134 Image 039_33. Cytomegalovirus Infection Cytomegalovirus infection with periventricular calcification
Red Book Online Visual Library, Image 039_33. Available at: Copyright ©2009 American Academy of Pediatrics

135 CMV Diagnosis Treatment Urine culture in the first 3-4 wks of life
Supportive

136 Herpes Simplex Virus Transmission usually from intrapartum contact
If Mom has active lesions or symptoms/ signs of prodrome C/S recommended Fetal transmission risk high among women who get their first episode of HSV at the time of delivery Low risk among women with recurrent herpes

137 HSV Presentation (1-2 weeks of life) 40 % SEM (skin, eye, mucosa)
Macular lesions that quickly vesicular on a red base Lesions occur at sites of trauma Fetal scalp monitor sites Eye margins On the presenting body part 35% CNS Encephalitis Focal neurologic signs Seizures 25% Disseminated In older kids, temporal szs

138 Image 060_34. Herpes Simplex Neonatal herpes simplex infection with disseminated vesicular lesions.
Red Book Online Visual Library, Image 060_34. Available at: Copyright ©2009 American Academy of Pediatrics

139 Image 060_40. Herpes Simplex Neonatal herpes skin lesions of the head and face. This is the same patient as shown in image 060_39. Red Book Online Visual Library, Image 060_39. Available at: Copyright ©2009 American Academy of Pediatrics

140 HSV Diagnosis HSV DFA or PCR Treatment IV Acyclovir

141 Syphilis Presentation HSM/ jaundice Rhinitis (“Snuffles”)
Pseudoparalysis of an extremitiy Uveitis/ chorioretinitis Skin rash Vesicular or vesiculobullous lesions superficial desquamation Hutchinson teeth

142 Image 128_42. Syphilis The face of a newborn infant displaying pathologic morphology indicative of "Congenital Syphilis" with striking mucous membrane involvement. Red Book Online Visual Library, Image 128_42. Available at: Copyright ©2009 American Academy of Pediatrics

143 Image 128_11. Syphilis Newborn with congenital syphilis with cutaneous ulceration (luetic gumma). These lesions are highly infectious. Red Book Online Visual Library, Image 128_11. Available at: Copyright ©2009 American Academy of Pediatrics

144 Image 128_18. Syphilis Hutchinson's teeth, a late manifestation of congenital syphilis. Changes occur in secondary dentition. The central incisors are smaller than normal and have sloping sides. Red Book Online Visual Library, Image 128_18. Available at: Copyright ©2009 American Academy of Pediatrics

145 Image 128_50. Syphilis This is the same child depicted in Image 128_10 of the collection. The mother of this six month infant was not screened for syphilis during pregnancy or at delivery due to a series of medical errors. The x-ray displays the characteristic "celery stalking" and widening of the metaphases in long bones found in untreated congenital syphilis. Red Book Online Visual Library, Image 128_50. Available at: Copyright ©2009 American Academy of Pediatrics

146 Fig 3.6. Algorithm for evaluation and treatment of infants born to mothers with reactive serologic tests for syphilis. Red Book Online Visual Library, Image FIGURE3F. Available at: Copyright ©2009 American Academy of Pediatrics

147 Teratogens/Maternal Drugs

148 “Fetal Anticonvulsant Syndrome”
Phenytoin a broad, low nasal bridge epicanthal folds wide-spaced eyes (hypertelorism) cardiovascular abnormalities distal digital hypoplasia (fetal hydantoin syndrome)

149 “Fetal Anticonvulsant Syndrome”
Valproic Acid increased risk for neural tube defects as well as cardiac, limb, and renal anomalies, and a characteristic facies (fetal valproate syndrome) Phenobarbital and carbamazepine also are associated with increased risks for malformations and dysmorphic features following prenatal exposure Valproate Syndrome

150 Isotretinoin “Accutane embryopathy”
Affects the craniofacial, CV, and CNS Microtia , depressed nasal bridge, ocular hypertelorism, cleft palate, macrocephaly Truncus arteriosus 35% risk in infants of women who take isotretinoin beyond 15 days after conception Maternal use prior to conception does not appear to be an increased risk for anomalies

151 Labor Drugs Terbutaline – tachycardia, hyperglycemia → hyperinsulinemia Indomethacin – premature closure of the ductus, oligohydramnios Magnesium – reduced heart rate, hypotonia, apnea, feeding intolerance, hypermagnesemia Opioid analgesic- decreased heart rate, poor suck and feeding (can be reversed with naloxone)

152 Lithium *Ebstein anomaly, ASD Thyroid function disturbances
Take precautions with breastfeeding

153 Coumadin “Fetal Warfarin Syndrome”
Hypoplastic nose Depressed nasal bridge Stippling of vertebrae Frequently have upper airway obstruction Most affected children do well The stippling is incorporated into calcifying cartilage and is no appears on radiographs after age 1

154 Fetal Alcohol Syndrome
short palpebral fissures thin vermilion border of the upper lip smooth philtrum evidence of pre- or postnatal growth restriction (height or weight <10th percentile) abnormal brain growth (head circumference <10th percentile) or brain development (structural brain anomalies).

155 Fetal Alcohol Syndrome
Infants also can be unusually hirsute (ethnicity always must be considered when judging hirsutism), and this feature typically dissipates over the first 6 postnatal months

156 Fetal Alcohol Syndrome
Although there is no well-characterized neonatal alcohol withdrawal syndrome, the physician should be alert to signs of drug withdrawal when FASD is suspected due to the frequent concomitant use of alcohol and drugs FAS is a frequently documented cause of mental retardation

157 Marijuana Not known to be associated with an increased incidence of birth defects, dysmorphic features, or developmental delay in exposed offspring, although further study is needed in this regard Prenatally exposed newborns may have tremulousness, increased irritability, and abnormal visual response to light stimulus

158 Tobacco Associations between maternal cigarette smoking and miscarriage, fetal growth restriction, preterm birth, and low birth weight A statistically significant increase in cleft lip +/- cleft palate was shown in at least one study *Increased risk for sudden infant death syndrome among exposed children Multiple studies examining the association between in utero cigarette smoke exposure (without postnatal environmental tobacco smoke exposure) and childhood respiratory disorders demonstrate a significantly increased prevalence of physician-diagnosed asthma and wheezing.

159 Opiates Places the newborn at risk for neonatal opiate withdrawal syndrome, often referred to as neonatal abstinence syndrome (NAS) May not become apparent until 5 days after birth For methadone-treated mothers, a higher daily methadone dose may be associated with a greater likelihood of the newborn experiencing NAS

160

161 Amphetamines *No amphetamine withdrawal syndrome has been described
No pattern of fetal anomalies attributable to maternal amphetamine ingestion Direct effects are: 1)Fetal growth restriction (due to vascular effects on the uteroplacental vasculature) 2) Neonatal agitation, irritability, and hypersensitivity to environmental stimuli 3) Potential developmental and cognitive impairment in early childhood Often associated with polydrug use

162 Cocaine Associated with vascular disruptive events in the embryo/fetus due to its potent vasoconstrictive and hypertensive effects Such events include cerebral infarction, urogenital anomalies, and limb reduction defects Placental abruption appears to be increased in cocaine-exposed pregnancies


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