Exam 5: Newborn & Infant Medicine:

What are common injuries that occur from birth trauma?

-Clavicular Fracture

-Humeral or Femoral Fracture

-Epiphyseal Fracture

-Brachial Plexus Injuries

-Spinal Cord Injuries

-Facial Nerve Palsy

-Sublegal Hemorrhage

Describe the signs of a clavicular fracture from birth trauma?

-decreased arm movement

-localized tenderness

-crepitus

What is the treatment for clavicular fracture from birth trauma?

no treatment or immobilization

Describe the signs of a humeral or femoral fracture from birth trauma?

-tenderness/swelling over shaft

-limited movement

What is the treatment for humeral or femoral fracture from birth trauma?

-immobilization 8-10 days

-ortho referral

Describe the signs of a epiphyseal fracture from birth trauma?

visible callus on XR after 8-10 days

What is the treatment for epiphyseal fracture from birth trauma?

-immobilization 8-10 days

-ortho referral

Describe the signs of a brachial plexus injury from birth trauma?

weakness & paralysis based on innervation

What is the treatment for brachial plexus injury from birth trauma?

-conservative (function usually returns

-PT

Describe the signs of a spinal cord injury from birth trauma?

-flaccid, quadriplegic

-absent respiratory effort

-facial movements intact

What is the treatment for spinal cord injury from birth trauma?

-poor prognosis

-respiratory support

Describe the signs of a facial nerve palsy from birth trauma?

-asymmetrical facial movements (seen with crying)

-from pressure against infant head

What is the treatment for facial nerve palsy from birth trauma?

spontaneously resolves

What is sublegal hemorrhage?

rare but potentially fatal condition that occurs when blood accumulates between the skull's periosteum and galea aponeurotica in a newborn

Describe the signs of a sublegal hemorrhage from birth trauma?

-hypovolemic shock

-blood loss

-coagulopathy

-bogginess in the back of neck/head

What is the treatment for sublegal hemorrhage from birth trauma?

emergency → rapid blood/clotting factor replacement

Define Sudden Infant Death Syndrome (SIDS).

sudden, unexpected death of an infant that’s unexplained after investigation → peaks at 2-4 months

Describe the history of Sudden Infant Death Syndrome (SIDS).

most deaths occur at night while infant and caregiver are sleeping

Describe the prevention of Sudden Infant Death Syndrome (SIDS).

-back to sleep

-room sharing on own sleep surface

-avoid loose bedding & stuffed animals

-breastfeeding, pacifiers

-no cigarettes

-only sleep in designated safe sleep space

-sleep sacks or wearable blankets are okay (non-weighted)

What are the clinical features of cocaine & methamphetamine in pregnancy?

-maternal hypertension

-decreased uterine blood flow

-fetal hypoxemia

-uterine contractions

-placental abruption

What are the clinical features of cocaine & methamphetamine in perinatal?

-increased stillbirth

-intrauterine growth restriction

-preterm delivery

What are the clinical features of cocaine & methamphetamine in infants?

-irritability

-tremors

-increased stress response

-poor state regulation

What is the workup of cocaine & methamphetamine?

maternal urine & fetal meconium and/or umbilical cord

What is the treatment of cocaine & methamphetamine?

treat symptoms and presentation

What is the prognosis of cocaine & methamphetamine?

-social services evaluation (higher risk of neglect)

-SIDS risk 3-7x higher

What are the clinical features of alcohol in infants?

-Fetal Alcohol Spectrum Disorder (FASD) & Fetal Alcohol Syndrome (FAS)

-Craniofacial abnormalities (small palpebral fissures, smooth philtrum, thin upper lip, microcephaly, low nasal bridge, ear abnormalities, ruptured nose, flattened midface)

-Growth abnormalities, neurobehavioral & developmental defects

What are the diagnostics of alcohol in infants?

-clinical based on history / presentation

-needs 3 diagnostic criteria: small palpebral fissures, smooth philtrum, thin upper lip

What is the treatment & prognosis of alcohol in infants?

-specific to symptoms

-neurodevelopmental delays common

What are the clinical features of tobacco in infants?

-intrauterine growth restriction

-low birth weight

-delayed growth rate

-irritability

-hypertonicity

-hyperexcitability

-tremors

What is the workup of tobacco in infants?

clinical

What is the treatment & prognosis of tobacco in infants?

specific to symptoms

What are the clinical features of marijuana in infants?

mild abstinence type syndrome

What is the workup of marijuana in infants?

toxicology on maternal drug screen

What is the treatment of marijuana in infants?

rarely required

What is the prognosis of marijuana in infants?

concern for long term impulsivity, hyperactivity, abstract thinking/visual reasoning difficulties

What is colic?

-severe paroxysmal crying in otherwise healthy infant

-MC 2-3 months

What is the history for colic?

-more episodes in the evening

-normal urine/stool/feeding

-ROS negative

What are the clinical features for colic?

-knees up, clenched fists, gassy

-pained appearance to face → minimal response to soothing

-Rule of Threes: crying for 3h+ per day for 3+ days per week for 3+ weeks

What are the physical exam findings for colic?

-normal vital signs

-appears well on exam

-crying but consolable during exam

What is the workup for colic?

thorough H&P → full head-to-toe exam, diagnosis of exclusion

What is the management for colic?

-reassurance, education, environmental modifications, soothing → NO meds

-consider dietary changes: changing formula to hydrolyzed/predigested or eliminate food groups from maternal diet if breastfeeding

What are the 5 S's of colic?

-swaddling

-side or stomach position

-shushing

-swinging

-sucking on pacifier

What is the prognosis for colic?

great, normally grows out of it at 12-16 weeks

What are the three major routes of perinatal infection?

-Transplacental (rubella, syphilis)

-Ascending infection via disruption of amniotic membrane barriers (bacterial infection)

-Exposure via passage through infected birth canal or exposure to infected maternal blood at delivery (HSV, hep B, bacteria)

What is the clinical presentation for fever?

-rectal temp >38ºC

-irritability, lethargic

-refusal to eat, dehydration

-febrile seizures, underlying etiology

What is the treatment for fever?

-acetaminophen for >2 months

-ibuprofen (10 mg/kg per dose) for >6 months

---educate on dosing, alternating medications not recommended

-Reassurance & supportive care (cool compress, don’t overdress, rest, fluids, hydration)

What is the cause of fever in Infants <28 days?

higher risk of serious disease (sepsis)

What is the workup of fever in Infants <28 days?

-CBC, blood culture, UA, urine culture

-CSF protein & glucose, CSF culture

-CXR if increased work of breathing

What is the treatment of fever in Infants <28 days?

send to ED if outpatient → hospitalization, IV antibiotics, consider antivirals or antifungals

What is the cause of fever in Infants 20-60 days?

-continued risk of invasive bacterial infections

-viral illness MCC, UTI MC bacterial

-toxic (decreased pulses, lethargic, not eating)

-nontoxic (fussy, clingy, but eating)

What is the treatment of fever in Infants 20-60 days? toxic vs nontoxic?

-toxic: admit and IV antibiotics, workup

-nontoxic: close outpatient follow up

What is the cause of fever in infants >60 days?

majority viral illness

What is the workup of fever in infants >60 days?

-culture for males <6 months and females <2 years

-CXR for increased work of breathing or high WBC

-consider blood cultures

What is the treatment of fever in infants >60 days?

-consider empiric antibiotic therapy if temp >39ºC and WBC >15k

-Consider observation without antibiotics if child is well appearing, fully immunized and with reassuring labs → inpatient vs outpatient

List the infections common in newborns & infants.

-Bacterial Sepsis:

-Meningitis

-Pneumonia

-Urinary Tract Infection (UTI)

-Omphalitis

-Conjunctivitis

Describe the CM of early onset of bacterial sepsis if <3 days of life ?

-respiratory distress

-poor perfusion

-hypotension

-low APGAR scores

Describe the CM of late onset of bacterial sepsis if >3 days of life?

-lethargy

-hypotonia

-poor feeding

-apnea

-temp instability

-new resp distress

What are the diagnostics for bacterial sepsis in infants?

-positive blood culture → low WBC, neutrophils, platelets. high immature/mature neutrophil ratio & inflammatory markers. metabolic acidosis, hypo/hyperglycemia

-LP to rule out meningitis & CSF infection

What is the treatment for bacterial sepsis in infants?

-antibiotics + hospitalization (10-24 days, IV

What is the treatment for early bacterial sepsis in infants?

ampicillin, gentamicin

What is the treatment for late bacterial sepsis in infants?

vanco + cephalosporin or aminoglycosides

What are the clinical manifestations of meningitis in infants?

sepsis, seizures

What are the diagnostics of meningitis in infants?

-lumbar puncture → positive gram stain, high protein & WBC, low glucose

-CSF culture: commonly GBS or gram (-) bacteria

What is the treatment of meningitis in infants?

IV antibiotics x 14-21 days

What is the prevention of meningitis in infants?

-intrapartum prophylactic antibiotics if group B strep positive, early treatment of sepsis

What are the clinical manifestations of pneumonia in infants?

-tachypnea

-retractions

-cyanosis

-respiratory support increase

What are the diagnostics of pneumonia in infants?

CXR → bilateral pulmonary opacities, focal infiltrates, air bronchograms

What is the treatment of pneumonia in infants?

IV antibiotics and respiratory support

What is the prevention of pneumonia in infants?

intrapartum Group B Strep prophylaxis

What are the clinical manifestations of UTI in infants?

-GU abnormalities

-fever

What are the diagostics of UTI in infants?

positive urine culture → gram negative enteric pathogens or enterococci

What is the treatment of UTI in infants?

IV antibiotics

What is the prevention of UTI in infants?

-GU consult for an abnormalities on US

-prophylactic antibiotics if indicated

What is Omphalitis?

infection of umbilicus

What are the clinical manifestations of Omphalitis in infants?

bacterial infection of soft tissues around umbilical stump, erythema, and edema

What is the treatment of Omphalitis in infants?

-surgical consult due to risk of progression to necrotizing fasciitis

-IV antibiotics

What is the prevention of Omphalitis in infants?

-keep the umbilical cord clean, open, and dry

-sponge baths until cord falls off and heals

What are the clinical manifestations for conjunctivitis in infants?

-conjunctival injection

-drainage/discharge

-can cause visual impairment, scarring

What is the treatment for conjunctivitis in infants?

-antibiotics specific to organism → NO topicals

What is are the two organisms for conjunctivitis in infants?

-N. Gonorrhoeae: copious purulent discharge

-Chlamydia: eye swelling, watery discharge

What is the treatment for the N. Gonorrhoeae: & Chlamydia conjunctivitis?

-gonorrhea: IV or IM ceftriaxone

-chlamydia: PO/IV/IM erythromycin

What is the prevention of conjunctivitis in infants?

-erythromycin ophthalmic ointment at birth prophylactically

-maternal routine STI screening

What are the risk factors for hypoglycemia?

-low gestational age, preterm,

-stressed

-diabetic mom

-genetic syndromes

-hyperinsulinemia

-glucose decreases after birth

What are the clinical features for hypoglycemia?

-asymptomatic

-lethargy, poor feeding, irritability, tremor, seizures

What are the glucose levels for hypoglycemia before 4 hours of life & at 4-24 hours of life?

-BG <40 before 4 hours of life

-BG <45 at 4-24 hours of life

What is the treatment for hypoglycemia?

enteral or parenteral glucose

What are the risk factors for respiratory distress in newborns & infants?

-MC pulmonary causes (transient tachypnea, aspiration syndrome, congenital pneumonia)

-airway, CNS, neuromuscular

What are the clinical features for respiratory distress in newborns & infants?

-tachypnea

-retractions (intercostal/sternal)

-expiratory grunting

-cyanosis

-nasal flaring

What are the diagnostics for respiratory distress in newborns & infants?

clinical → pulse-ox, CXR, arterial blood gas, CBC, blood culture, blood glucose

What is the treatment for respiratory distress in newborns & infants?

-respiratory support (goal O2 sat 91-96%)

-treat underlying cause

Describe the patho of jaundice.

breakdown of heme → converted to unconjugated bilirubin → binds to albumin & taken up in liver → becomes conjugated → excreted through bile to intestines & excreted in stool

What are the risk factors for physiologic jaundice?

-lower gestational age

-jaundice within 24 hrs after birth

-hemolysis (bruising/hematoma)

-rapid rise in serum bilirubin level

-breastfeeding

-macrosomia, infant of diabetic mother

Describe the patho for physiologic jaundice?

newborns have immature livers, absence of gut flora, & slow GI motility → bilirubin accumulation

What are the clinical features for physiologic jaundice?

-visible jaundice & scleral icterus

-peak bilirubin levels at 3-5 days of life

What is the workup for physiologic jaundice?

-total bilirubin rises by <5 mg/dL/day

-total bilirubin level is <15 mg/dL

What is the treatment for physiologic jaundice?

self resolves in 1-2 weeks

Describe the patho of Pathologic Unconjugated Hyperbilirubinemia.

-overproduction of bilirubin

-decreased conjugation of bilirubin

Describe the presentation of Pathologic Unconjugated Hyperbilirubinemia.

-jaundice

-scleral icterus

What are the diagnostics of Pathologic Unconjugated Hyperbilirubinemia?

-elevated serum unconjugated bilirubin level

-concern for significant hemolysis if jaundice & bilirubin >5 mg/dL prior to 24 hours of life

What is the treatment of Pathologic Unconjugated Hyperbilirubinemia?

-phototherapy (blue light)

-exchange transfusion (if phototherapy doesn't work)

-IVIG if immune-mediated, fluids, increasing feeds (formula supplementation)