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Pediatrics - Neonates
Terms in this set (155)
What are the five layers of the neonatal rescuscitation pyramid?
1. position, suction, warm, dry, stimulate
3. Ventilation (BVM or ET tube)
4. Chest Compressions
When does a neonate require ventilation?
apnea or HR < 100
When does a neonate require chest compressions?
If HR < 60
How common is the presence of meconium at delivery?
What 3 conditions result from Meconium Aspiration Syndrome?
How is meconium aspiration prevented?
suctioning of the airway prior to baby's first breath
What is the correct positioning for a neonate during rescuscitation?
neck slightly extended
At what rate is blow by Oxygen administered during neonatal rescuscitation?
10 Liters per min
At what rate is a neonate ventilated with a BVM during rescuscitation?
40-60 breaths per minute
When is an ET tube considered in neonatal rescuscitation?
resistant to the BVM or for transport
What medications can be administered via ETT?
"NAVEL" (Narcan, Atropine, Valium, Epinephrine, Lidocaine)
At what rate should chest compressions be administered in neonatal rescuscitation?
120 per minute
What ratio are ventilations and compressions given during neonatal rescuscitation?
what are the two methods of chest compressions in neonates?
two thumbs (preferred)
what is an indication for narcan and when should it be administered to a neonate?
used for maternal narcotic use; use within first 4 hours
What amount of IV fluids should be administered to a neonate that is hypotensive?
10 mL per kg of NS or LR
What are the components of an Apgar score?
1. Appearance (color)
3. Grimace (stimulus with bulb suction)
4. Activity (tone)
what are the possible scores in each Apgar category?
0, 1 or 2
What score is given for pulse in a neonate with a HR of 85 bpm?
what is the highest possible Apgar score?
what are the three Apgar descriptions for Appearance?
cyanotic - 0
acrocyanotic - 1
pink - 2
what are the three Apgar descriptions for pulse?
none - 0
< 100 - 1
> 100 - 2
what are the three Apgar descriptions for grimace
none - 0
grimace - 1
cough/sneeze - 2
what are the three Apgar descriptions for Activity?
limp - 0
some flexion - 1
active motion - 2
what are the three Apgar descriptions for Respiration?
none - 0
irregular/weak cry - 1
vigorous cry - 2
when is an Apgar test performed?
10 min (if previous was < 6)
What dictates rescuscitation efforts?
Rescuscitation pyramid, not Apgar score
Does an Apgar score predict long term outcome?
No, only a short term prognosis
what is the purpose of erythromycin ophthalmic ointment?
to prevent chlamydial conjunctivitis
what vaccine is offered in the nursery immediately after birth?
What neonatal health screening is required by law?
Thyroid screen- congenital hypothyroidism
maple syrup urine disease
hemoglobin electrophoresis - anemias (sickle-cell)
what test is used for newborn metabolic screening?
Tandem Mass Spectrometry - allows for rapid diagnosis of numerous metabolic diseases with a single blood donation
What vitamin supplements are given to a neonate in the nursery?
iron (in formula)
What is the purpose of a Ballard Score?
Differentiate IUGR from prematurity
Evaluate age vs. weight
What is the definition of large for gestational age? What are the health concerns for LGA?
> 90th percentile
neonatal hypoglycemia associated with maternal gestational diabetes
What is the definition of small for gestational age? what are the health concerns for SGA?
< 3rd percentile
Symmetric-Early prenatal infections or genetics
Asymmetric- Late "uteroplacental insufficiency"
What body parts are examined to calculate a Ballard Score?
skin, lanugo, breast buds, plantar creases, ears, genitals
what are normal vital signs for a neonate?
HR 120-160, resp 30-60, temp < 100.4, BP 70/50
What is considered an enlarged fontanelle and what does it indicate?
>4 cm; hypothyroidism
What is indicated by a closed fontanelle?
what are you checking for when performing and EENT exam on a neonate?
Note patency, ear tags, cleft lip, suck reflex
Bilateral red reflex
what is indicated by a neck bulge at the Anterior midline?
What is indicated by a neck bulge between the anterior to SCM?
brachial cleft cysts
What is indicated by a neck bulge between the posterior to SCM?
What is indicated by LE pulses < UE
coarctation of the aorta
What is the normal number of umbilical vessels in a neonate?
2 arteries (deoxy)
1 vein (oxy)
1% will have only 2 vessels; more common in twins; does not require any additional tests but be alert for other anomalies
What is indicated by an Elevated pulse pressure? decreased pulse pressure?
Patent Ductus Arteriosus (PDA)
Coarctation of the Aorta
How is pulse pressure calculated?
systolic BP - diastolic BP
What tests are used to assess hip dislocation?
Barlow ("click" when hip dislocates posteriorly)
Ortalani ("clunk" when hip relocates anteriorly)
What is indicated by Asymmetry of the Transverse Gluteal Crease?
Congenital Diaphragmic Hernia (CDH)
What are the five major neonatal reflexes and when should they disappear?
Rooting (gone by 2 months)
Fencer reflex (gone by 4 months)
Moro (gone by 4 months)
Grasp (gone by 4 months)
What do you inspect the placenta for?
size, shape, smell, color, consistency, completeness, infarcts, hemorrhages, tumors, nodules, meconium staining, # of vessels, knots, length of cord
What intervention is required for overiding cranial sutures in a neonate?
none, it is a common finding and resolves in 24-48 hours
What is the term for cone shaped or swollen cranium that crosses cranial suture lines? What intervention is required?
Caput Succedaneum - No treatment is necessary, and it usually heals spontaneously within a few days
What is swelling of the cranium that does not cross cranial suture lines?
What is another sign of subgaleal hemorrhage?
Ears are pushed anteriorly
What is the intervention required for subgaleal hemorrage?
compression and resuscitation
What is indicated by macrocephalic cranium and "sunset eyes"?
What causes the "sunset eyes" in hydrocephalus?
Cranial nerve III palsy (inhibits upward gaze)
how is anenchephaly found on physical exam?
transillumination of the cranium
Transillumination reveals a posterior fossa cyst. What is this malformation?
What causes a Dandy-Walker Malformation?
complete or partial agenesis of the vermis (midline of cerebellum), cystic dilation of 4th ventricle and enlarged posterior fossa
What is the term for white reflex in one eye?
What eye disorders can present with leukocoria?
congenital cataracts, corneal scarring, retinoblastoma
What anomalies can be found on the gums of a neonate?
Epstein pearls - benign sebaceous cyts that resolve spontaneously in 1-2 weeks
What physical characteristics of a neonate indicate Trisomy 21?
Ears set low and posteriorly rotated
prominent epicanthal folds (almond eyes)
Brushfield spots around the iris
flat facial profile
space between 1st and 2nd toes
What intervention is required for umbilical hernia?
none, usually resolves by 12 months
what intervention is required for supraumbilical hernia?
may require surgery
A hydrocoele may indicate what other abnormality?
When should a neonate pass meconium?
within first 24 hours of life
What is the term that means too many digits? fused digits?
What is the term for medial deviation of the mid and forefoot?
What intervention is required for metatarsus adductus?
serial casting if not readily reducible
what is the term for inversion, adduction and plantar flexion of the foot
Clubfoot (Talipes Equinovarus)
What are the two types of Talipes Equinovarus and what causes them?
Extrinsic (supple) - Due to uterine molding
Intrinsic (rigid) - Idiopathic cause resulting in abnl bone structure
What is the treatment for Intrinsic talipes equinovarus?
surgery or serial casting
What is a potential complication of forceps delivery?
facial nerve palsy (Cranial Nerve VII)
What are the two types of brachial plexus injuries during delivery?
Erb-Duchene's palsy and Klumpke's palsy
What are the indications of Erb-Duchene's palsy?
"Waiter's tip" palsy
Biceps reflex absent
Grasp reflex present
What causes Erb-Duschene's palsy
phrenic nerve lesion
What are the indications of Klumpke's palsy?
Grasp reflex absent
Biceps reflex present
associated with horner's syndrome (eyelid droop, anhidrosis)
What causes Klumpke's palsy
A neonate presents with pustules with pigmented base on head, neck, back and extremities. What is it?
What is the treatment for pustular melanosis?
resolve spontaneously in 3 months
They are sterile lesions (contain neutrophils)
A neonate presents with pustules with erythematous base on trunk and back that appeared 24-48 hrs post-birth. What is it?
Erythema Toxicum Neonatorum
What is the treatment for Erythema Toxicum Neonatorum?
none required. these sterile lesions resolve in 5-7 days
What causes milliaria crystalina/rubra? what is the treatment?
Crystalina: superficial sweat gland (eccrine) obstruction without erythema
Rubra: Deeper eccrine gland obstruction resulting in erythematous base
Both due to heat, moisture. Treatment is to keep dry and open to the air
What causes neonatal acne? When does it appear?
Due to maternal hormones seen in the first few months of life. Most common at 4-6 weeks and disappears over few weeks
What does reticular mottling of the skin in a neonate indicate?
Physiologic response to cold up to age 4-6 months. If persistent may be indicator of hypothyroidism or other congenital condition.
When do strawberry hemangiomas usually clear?
by 9 years of age
What are the three major risk factors for Sepsis?
Prematurity (6x greater)
Prolonged rupture of membrane (PROM) >18 hrs before birth
Maternal Group B Strep (GBS) colonization
What two conditions present very similarly to neonatal sepsis?
Respiratory Distress Syndrome (RDS)
What pathogens are most common in Early Onset Sepsis?
What pathogens are most common causes of Late Onset Sepsis?
What is the definition of early onset sepsis? late onset
< 7 days after birth
> 8-28 days after birth (usually discharged in good health)
Which type of sepsis is more commonly associated with meningitis (early or late)?
Which type of sepsis has a more insidious onset (early or late)?
What is the most common cause of neonatal early onset sepsis?
bacterial infection acquired from maternal GU tract
What is the treatment for neonatal sepis (early and late onset)?
IV ampicillin and gentamycin (after labs drawn)
X 14 days for Sepsis
X 28 days for Meningitis
Meningitis and RDS receive same empiric treatment
consider vancomycin for late onset or meningitis
What labs and rads are performed when neonatal sepsis is suspected?
CBC, BC x 2, UA, UC and glucose
CXR if respiratory sxs
Consider lumbar puncture
(limited eval = CBC + BC x 2)
Does a septic neonate always present with a fever?
Most often yes but sometimes thermoregulatory instability can cause hypothermia as well.
A mother is known to be +GBS, when does the neonate require a sepsis workup?
born < 35 weeks - limited eval and 48 hr observation
mother did not receive abx - limited eval and 48 hr observation
full eval if sepsis is suspected
What are the most common causes of respiratory distress in preterm neonates?
Sepsis / Pneumonia
Respiratory distress syndrome (RDS)
Apnea of prematurity
What are the most common causes of respiratory distress in term neonates?
Sepsis / Pneumonia
Meconium aspiration syndrome (MAS)
Transient tachypnea of the newborn (TTN)
Primary persistent pulmonary hypertension (PPHN)
What is the cause of RDS?
too little surfactant production by pneumatocytes resulting in end expiratory atelectasis. more common in < 34 weeks gestation
How does RDS appear on CXR?
"ground glass" appearance (appears 6-12 hours after birth)
What is the treatment for RDS?
Maternal steroids prior to delivery (32-34 wks)
Intubation and respiratory support
Artificial surfactant via ET tube
What are possible complications of RDS?
Persistent patent ductus arteriosus
Bronchopulmonary dysplasia (BPD)
Retinopathy of prematurity (ROP)
What causes apnea of prematurity?
Central - Medulla and pons don't stimulate phrenic nerve
Peripheral - Airway obstruction due to malformation or positioning
what are the treatment options for apnea of prematurity
Stimulants (caffeine or theophylline)
What are the potential complications from meconium aspiration?
pneumonia (chemical and bacterial)
What does meconium aspiration appear as on CXR?
Coarse, irregular infiltrates
What is transient tachypnea of the newborn (TTN)?
Retained amniotic fluid causing Tachypnea (60 / min or more) leading to mild hypoxia
How does TTN appear on CXR?
fluid in the fissures
Who is at risk for developing TTN?
Hypoxia without evidence of structural cardiac or pulmonary disease is called?
primary pulmonary hypertension
What does primary pulmonay HTN look like on CXR?
What pathogens cause pneumonia in the newborn?
same as sepsis:
What is the definition of hypoglycemia?
blood glucose < 45 mg/dL with symptoms
Wpreemies may tolerate lower blood sugar
What are the three common causes of hypoglycemia in the newborn?
Intrauterine growth restriction (IUGR)
What are the signs and symptoms of hypoglycemia in the newborn?
Lethargy, poor feeding, hypotonia
May cause jitteriness and seizures
What is the treatment for hypoglycemia in the newborn?
Blood sugar 20-40 & no symptoms:
Oral feeds and monitor with repeat testing
BS 20-40 with symptoms or BS < 20
Bolus D10W at 2 cc/kg then 6 mg/kg/min
Treat underlying cause if possible
What are the three types of hemolytic diseases of the newborn?
ABO incompatibility (most common)
Other antigen incompatibilities
Rh C, E, Kell, Duffy, etc.
What are the birth related causes of blood loss in newborns?
Maternal-fetal hemorrhage—fetal RBCs enter maternal circulation
Cord rupture / early cord clamping
What are the iatrogenic causes of blood loss in newborns?
drawing too much blood for labs
What are the three reasons that all neonates have elevated bilirubin?
Increased RBC mass and turnover
Insufficient hepatic clearance (less UDPGT)
Decreased gut motility / excretion
What are the basic products of RBC destruction?
Heme (Biliverdin,CO2, Fe)
What enzyme in the blood converts biliverdin to bilirubin?
bilirubin reductase (blood)
What enzyme in the liver conjugates bilirubin?
UDPGT = Uridine diphosphate glucuronyltransferase (liver)
What does it mean to conjugate bilirubin?
Addition of 2 glucuronides making it water soluble
What converts conjugated bilirubin to stercobilin?
normal gut flora
What are the two types of neonatal jaundice?
Breast milk jaundice
what are the causes of unconjugated (indirect) pathological jaundice?
ABO / Rh isoimmunization
Hemorrhage / hematoma / sepsis
Nonimmune (spherocytosis, G6PD)
Hypothyroidism / hepatic disease
Gilbert's (common - asymptomatic)
Crigler-Najjar (rare-profound jaundice
what is the main cause of conjugated (direct) pathological jaundice?
Obstruction distal to liver
What is the cause of breast feeding jaundice?
Lack of adequate feeds = decreased gut motility
Usually occurs at 2-3 days after birth
What is the cause of breast milk jaundice?
Fatty acids displace bilirubin from albumin
Usually occurs at 7-10 days after birth
What is kernicterus?
bilirubin induced brain dysfunction
What three factors make jaundice more likely to be pathologic (kernicterus causing)?
Peak level > 15 mg/dl (age dependent)
rate of rise > 5mg/dl per day
onset within 24 hours of life (this is abnormal)
At what level does hyperbilirubinemia become visibly evident?
What is the first location on the body that jaundice is visible?
under the tongue, then sclera, then progresses head to toe
What is a Coomb's test?
Direct Antiglobin Test (DAT)
Indirect Antiglobin Test (IAT)
What are the uses of the Coombs tests?
DAT- pretransfusion screening
IAT- screen pregnant mothers for antibodies that cause Hemolytic Disease of the Newborn
What labs should be ordered in a neonatal jaundice workup?
Total bilirubin (direct & indirect)
Consider G6PD (African, Asian, Med. male)
What level of bilirubin is considered dangerous for kernicterus?
neonates are susceptible at lower levels
What are the treatment options for neonatal jaundice?
Lifestyle changes:Improve / increase feeding
Exposure to indirect sunlight
Phototherapy (term & workup nl)
Is breastmilk jaundice an indication to stop breastfeeding?
What wavelength of UV light breaks down bilirubin?
425-475 nm "Bili-lights."
What are the reversible causes of seizures in neonates?
Hypoglycemia, hypocalcemia, sepsis / encephalitis, kernicterus, drug withdrawal
What are the irreversible causes of seizures in neonates?
Metabolic syndromes, familial seizures, ischemia
How are seizures in a neonate recognized?
very subtle, look for rhythmic patterns; EEG often required for diagnosis
What tests are included in a seizure workup?
CBC, Chem 7 (Na, Glu) + Ca
If those normal, EEG and MRI are common follow-up tests
What is necrotizing enterocolitis?
Severe gut dysfunction due to feeding a premature GI tract
caused by ischemia not infection
How does necrotizing enterocolitis present?
rectal bleeding in a premature infant
May be severe (DIC and shock)
How does nectrotizing enterocolitis appear on radiograph?
Gas between the subserosal and muscularis layer of the small bowel wall
May also show illeus or free peritoneal air
What is the treatment for necrotizing enterocolitis?
Broad spectrum abx
Surgical excision (~50%)
This set is often in folders with...
Neonatal and Pediatrics
Neonatal/Pediatric Resp. Care
Nursing Process Applied to the Neonate
Neonatal and Pediatric Respiratory Disorders
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