CHAT - NEONATOLOGY I

What is the definition of the neonatal period?

The first 28 days of life after birth

How is the neonatal period subdivided?

Early neonatal period: 0–7 days; Late neonatal period: 8–28 days

Why is the neonatal period considered highly vulnerable?

Newborns undergo many physiological adjustments for extrauterine life, making them prone to illness

What are the characteristics of a sick newborn?

Appears unwell or lethargic, has systemic illness, poor weight gain, requires additional support such as oxygen, IV fluids, or medications

Why is obtaining a good history important in sick newborns?

To determine the nature of the illness and presence of maternal and fetal risk factors during pregnancy and delivery

Why is meticulous examination crucial for sick newborns?

It provides clues to the etiology of the sickness and forms the basis for management

What are the main causes of neonatal deaths worldwide according to 2012 data?

Prematurity and low birth weight (~33%), perinatal asphyxia (~10%), congenital infections (TORCH), acquired infections (sepsis, pneumonia), congenital malformations (~10%)

What percentage of under-5 deaths occur in the neonatal period?

Approximately 47%

What is the main trio responsible for 85–90% of neonatal mortality?

Prematurity, low birth weight/intrauterine growth restriction (IUGR), and serious infections & birth asphyxia

What is perinatal period defined as?

28th week of gestation to the 7th day postpartum

What are the two subcategories of the neonatal period?

Early neonatal period: 0–7 days; Late neonatal period: 8–28 days

Which cause of neonatal death is most common worldwide?

Prematurity

List some long-term complications of perinatal asphyxia.

Impaired attention span, hyperactivity, epilepsy, mental retardation, auditory deficits

Name some conditions that can affect a newborn starting in utero.

Prematurity, congenital malformations

Name some conditions that can affect a newborn during birth.

Birth injuries, asphyxia

Name some conditions that can affect a newborn postnatally.

Acquired infections such as sepsis and pneumonia

Why is it essential to recognize non-specific signs in newborns?

Because early recognition allows prompt management and improves outcomes

What proportion of infants require resuscitation at birth?

A small proportion, usually due to respiratory problems causing inadequate ventilation

What is the main cause of cardiac arrest in newborns?

Inadequate ventilation (unlike adults where inadequate circulation is the main cause)

What are the primary goals of neonatal resuscitation?

To establish adequate, spontaneous respiration, ensure adequate cardiac output, and prevent morbidity and mortality from hypoxemic tissue injury

What situations should be anticipated to improve neonatal resuscitation outcomes?

High-risk pregnancies identified from history, labor complications, prenatal diagnosis of fetal anomalies, and improved perinatal care

List the objectives of neonatal care.

Establish and maintain cardio-respiratory function, maintain body temperature, avoid infection, establish satisfactory feeding, early detection of congenital or acquired problems

When should resuscitation be started for a newborn?

Immediately if the baby is limp, cyanotic, apneic, or pulseless, before assigning the first minute APGAR score

What is the main goal within the first minute of life (golden minute)?

To establish effective ventilation

Why is positive pressure ventilation (PPV) indicated in newborns?

Heart rate

What equipment is used to monitor a baby during PPV?

Pulse oximeter and ECG monitor (optional)

How soon should the heart rate and chest movement be assessed after starting PPV?

After the first 15 seconds

What corrective steps are suggested if heart rate does not improve during PPV?

MR SOPA: Mask adjustment, Reposition head, Suction mouth & nose, Open mouth, Pressure increase, Alternate airway

When should chest compressions be initiated in neonatal resuscitation?

If heart rate falls below 60 bpm despite 30 seconds of effective ventilation

What is the recommended compression-to-ventilation ratio in neonates?

3:1 (90 compressions and 30 breaths per minute)

When should IV epinephrine be administered during neonatal resuscitation?

If heart rate remains

What underlying conditions should be considered if bradycardia persists despite resuscitation?

Pneumothorax and hypovolemia

What is the correct head position for establishing a patent airway in a newborn?

Slight extension of the head in a sniffing position

What steps are included in the ABCs of neonatal resuscitation?

Airway: ensure patency; Breathing: tactile stimulation, PPV, ETT if needed; Circulation: chest compressions and medications

What is the first step after receiving a newborn under the radiant warmer?

Dry the baby with warm linen and assess breathing/crying

What is the initial intervention for a baby who is not breathing properly or limp?

Provide drying, stimulation, reposition head, clear airway, then start PPV if needed

What is the next step if a baby has spontaneous but labored breathing or cyanosis?

Give oxygen supplementation or consider NCPAP

True or False: All babies need resuscitation at birth.

False. All babies must be assessed, but only those who need it should receive resuscitation

What is the recommended intervention for a 5-day old intubated preterm infant with HR

Start ambu-bagging with higher pressure (PPV)

Question

Answer

What are common CNS disorders in neonates?

Important causes of neonatal mortality and morbidity; CNS can be damaged from asphyxia, hemorrhage, trauma, hypoglycemia, or direct cytotoxicity.

What are common etiologies of neonatal CNS disorders?

Multifactorial: perinatal complications like hypoxic-ischemic encephalopathy (HIE), postnatal hemodynamic instability, developmental abnormalities (genetic or environmental).

What are predisposing factors to neonatal brain injury?

Acute/chronic maternal illness causing utero-placental dysfunction, intrauterine growth restriction, premature births, unavoidable emergencies during delivery.

What causes cranial hemorrhage in neonates?

Birth trauma or asphyxia, mechanical forces during delivery (e.g., forceps, vacuum).

What is Caput Succedaneum?

Diffuse, sometimes ecchymotic, edematous swelling of scalp soft tissue; crosses sutures; resolves in 48-72 hrs; no intervention needed; minimal blood loss.

What is Cephalohematoma?

Bleeding confined under periosteum over parietal bones; does not cross sutures; associated with linear fracture in 10-20% of cases; resolves in 2-3 weeks; rarely neurologically significant.

What is Subgaleal Hemorrhage?

Bleeding beneath epicranial aponeurosis; may extend to orbits/neck; strongly associated with vacuum delivery; can cause massive blood loss and hypovolemic shock; requires urgent management.

What is Intraventricular Hemorrhage (IVH)?

Most common CNS complication of preterm birth; occurs in germinal matrix; may rupture into lateral ventricles; associated with prematurity, hypoxemia, infection, or trauma.

Which neonates are most susceptible to IVH?

Preterm infants due to limited cerebral autoregulation, highly vascularized germinal matrix, and fragile blood vessels.

What is the timing of IVH in preterm infants?

Majority occur in first 3 days; 50% within 5 hours, 70% in first day, 95% by day 7; rare after first month.

How is IVH graded?

Grade 1: GM only or

What is Periventricular Leukomalacia (PVL)?

Focal necrosis in periventricular white matter; cystic or diffuse; associated with severe IVH or ventriculomegaly; leads to motor abnormalities like cerebral palsy.

What causes neonatal seizures?

Asphyxia (HIE), post-hemorrhagic events (IVH, subarachnoid hemorrhage), metabolic disturbances, toxins, infections, malformations, genetic disorders, trauma.

What are types of neonatal seizures?

Subtle (automatisms), clonic (focal or multifocal), tonic (stiffening/posturing), myoclonic (rapid jerks).

What is perinatal asphyxia?

Lack of spontaneous or effective breathing after birth; results from hypoxia/ischemia; emergency requiring resuscitation; affects multiple organ systems.

What organs are most affected by perinatal asphyxia?

CNS (HIE, seizures), cardiovascular (myocardial ischemia), pulmonary (pulmonary hypertension), renal (acute tubular necrosis), adrenal (hemorrhage), GI (necrosis/ulceration), metabolic (hypoglycemia, hyponatremia), integumentary, hematologic (DIC).

What is Hypoxic-Ischemic Encephalopathy (HIE)?

Brain injury after asphyxia; reduced cerebral blood flow → decreased oxygen/glucose → low ATP → neuronal necrosis/apoptosis; primary and secondary energy failure.

What is primary energy failure in HIE?

Immediate neuronal necrosis due to severe hypoxia/ischemia; necrosis or apoptosis occurs depending on insult severity.

What is secondary energy failure in HIE?

Occurs 6-48 hrs post insult; caused by oxidative stress, excitotoxicity, inflammation; contributes to neuronal apoptosis/necrosis.

What is the modified Sarnat staging for neonatal encephalopathy?

Stage 1 (mild): hyperalert, normal tone, no seizures; Stage 2 (moderate): lethargic, hypotonic, common seizures; Stage 3 (severe): stuporous/coma, flaccid, decerebrate, abnormal EEG, poor outcome.

What are poor predictive variables for death/disability after HIE?

APGAR 0-3 at 10 min, need for CPR, delayed spontaneous breathing, severe neurologic signs, seizures ≤12 hr or refractory, prolonged EEG abnormalities, basal ganglia/thalamic lesions, oliguria/anuria >24 hr, abnormal neuro exam ≥14 days.

What spinal cord injury mechanism is common in neonates?

Stretching of the spinal cord due to longitudinal traction on trunk while head is engaged during delivery.

Question

Answer

What is the most frequent cause of NICU admission in term and preterm infants?

Respiratory disorders

What is required for successful transition from placental-derived oxygen delivery to pulmonary respiration?

Timely clearance of fetal lung fluid, creation of functional residual capacity, increased pulmonary blood flow, and establishment of normal breathing patterns

What does tachypnea in a neonate indicate?

Inadequate oxygenation or ventilation

What does bradypnea indicate in preterm and term infants?

Preterm: respiratory fatigue; Term: central (CNS) cause

What is the significance of grunting in neonates?

To maintain functional residual capacity; decreasing grunting indicates improvement

What do retractions indicate in neonatal respiratory distress?

Reduction in lung compliance; attempt to increase negative intrapleural pressure

What does nasal flaring indicate?

Decrease airway resistance

What does cyanosis indicate in a neonate?

Increase in desaturated hemoglobin (>3-5 g/dl)

Why might a neonate show decreased activity in respiratory distress?

Secondary to hypoxia or an attempt to conserve energy

What is the purpose of a chest X-ray in neonates with respiratory distress?

To detect reticulogranular pattern of RDS, pneumothorax, cardiomegaly, or congenital anomalies

Why order an arterial blood gas in neonatal respiratory distress?

To assess severity of hypoxemia, hypercapnia, and type of acidosis

Why is CBC ordered in neonatal respiratory distress?

To determine anemia/polycythemia, sepsis, or DIC

Why is blood culture requested in neonatal respiratory distress?

To identify potential pathogens for targeted treatment

Why check blood glucose in neonates with respiratory distress?

To detect hypoglycemia or stress hyperglycemia contributing to distress

When is echocardiography indicated in neonatal respiratory distress?

Presence of murmur, cardiomegaly, or refractory hypoxia to detect CHD or PPHN

Name common pulmonary causes of neonatal respiratory distress.

Hyaline membrane disease, meconium aspiration syndrome, congenital pneumonia, transient tachypnea of the newborn, bronchopulmonary dysplasia, pulmonary hemorrhage, air leak

Name congenital airway obstruction causes of neonatal respiratory distress.

Choanal atresia, nasal edema, macroglossia, micrognathia, retrognathia, subglottic stenosis, laryngomalacia, tracheomalacia, congenital tracheal stenosis

Name intrathoracic malformations causing neonatal respiratory distress.

Pulmonary hypoplasia/agenesis, diaphragmatic hernia, intrathoracic cyst, congenital lobar emphysema

Name extrapulmonary causes of neonatal respiratory distress.

Cardiac: CHD, CHF, arrhythmia; Metabolic: hypoglycemia, hypocalcemia, metabolic acidosis, hypothermia; Neurological: HIE, neonatal seizure, intracranial bleed; Hematologic: anemia, polycythemia

What is Downe’s scoring system used for?

Assessing severity of respiratory distress in term neonates

What Downe’s score indicates severe respiratory distress?

Score >6

What is Silverman scoring system used for?

Assessing severity of respiratory distress in preterm neonates

What Silverman score indicates need for ventilation in preterm infants?

Score >8

What is the pathogenesis of Respiratory Distress Syndrome (RDS)?

Surfactant deficiency → alveolar atelectasis → decreased functional residual capacity → hypoxemia, hypercapnia, and respiratory distress

List predisposing factors for RDS.

Prematurity, male sex, maternal diabetes, second born twins, cesarean delivery, perinatal asphyxia, multiple birth, precipitous delivery, cold stress, previous affected infant

List protective factors against RDS.

Pregnancy-associated hypertension, maternal heroin use, PROM, IUGR, antenatal corticosteroid prophylaxis

What are strategies to prevent preterm birth and RDS?

Maternal cervical cerclage, bed rest, infection treatment, tocolytics, antenatal corticosteroids (betamethasone 12mg IM q24h x2 or dexamethasone 6mg IM q12h x4)

What is the mainstay of treatment for RDS?

Supportive care, oxygen, mechanical ventilation if needed, intratracheal surfactant administration

What is Bronchopulmonary Dysplasia (BPD)?

Chronic lung disease of prematurity characterized by prolonged oxygen requirement and lung injury from RDS or ventilation

What is the pathophysiology of BPD?

Immature lung + surfactant deficiency + barotrauma/volutrauma + oxygen toxicity → inflammation, alveolar injury, impaired lung development

What are risk factors for BPD?

Extreme prematurity, prenatal/postnatal infections, PDA with excessive pulmonary blood flow, excessive IV fluids, pulmonary hypertension

How is BPD classified?

Mild: O2

What is the clinical manifestation of BPD?

Oxygen dependence, hypercapnia, pulmonary hypertension, poor growth, right-sided heart failure, increased airway resistance, chest retractions

What is Meconium Aspiration Syndrome (MAS)?

Respiratory distress in newborns born through meconium-stained amniotic fluid, may lead to mechanical pneumonitis and PPHN

What is the pathophysiology of MAS?

Partial airway obstruction → ball valve effect → air trapping; complete obstruction → atelectasis; surfactant inactivation; pulmonary hypertension

What is the management of MAS?

Supportive care, oxygen, ventilation if needed, surfactant for severe hypoxia, nitric oxide, ECMO for OI >25

What is Transient Tachypnea of the Newborn (TTN)?

Self-limiting tachypnea in term or late preterm infants due to delayed clearance of lung fluid