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Date posted: April 25, 2012

These secrets are 100 of the top board alerts.

They summarize the concepts, principles, and most  salient details of fetal and neonatal medicine.

  1. A normal biophysical profile (BPP) is never associated with fetal acidemia.
  2. Fetal hydrops is a harbinger of fetal demise.
  3. Primary complications of fetal surgery are premature labor and preterm delivery.
  4. Liver position and lung-to-head ratio relate to prognosis in congenital diaphragmatic hernia, whereas in congenital cystic adenomatoid malformation, morphology is a better prognostic indicator than histology. Mortality from sacrococcygeal teratoma is inversely related to gestational age at diagnosis.
  5. Selective laser photocoagulation is the only potentially curative intervention in twin-twin transfusion syndrome.
  6. The fastest way to obtain results of chromosomal analysis for genetic testing of amniotic fluid is through fluorescent in situ hybridization (FISH).
  7. Cigarette smoking and cocaine are important causes of placental abruption.
  8. A Kleihauer-Betke test remains the best way to determine fetal-maternal bleeding.
  9. The absence of fetal fibronectin in cervicovaginal secretions has excellent negative predictive value in ensuring that delivery is not imminent.
  10. Multiple courses of antenatal steroids (>3) may be associated with subsequent reduction of brain growth in the fetus and neonate.
  11. Progesterone administration appears to be the most effective way to prevent premature delivery at present.
  12. The BPP consists of fetal movement, fetal breathing movements, fetal tone, amniotic fluid volume, and fetal heart rate monitoring. A BPP score <6 is worrisome and needs careful attention.
  13. Flow reversal through the umbilical artery during diastole is a critical measure of impending fetal demise, especially in a growth-retarded infant.
  14. Developmental care such as paying attention to light, sound, handling, and touch in the neonatal intensive care unit (NICU) can improve the medical outcome of critically ill infants.
  15. Including parents as part of the care team reduces infant pain and stress and improves the medical outcome. Also pay attention to infant responses or cues. Premature infants who shield their face with their hands are not saying hello; they are letting you know they have had enough stress.
  16. The senses continue to develop in the NICU, beginning with touch and ending with vision. Neuronal connections will be affected by negative and positive environmental influences.
  17. The brain of the premature infant is primed to respond to pain in the NICU. Shield the infant from light and provide containment with pacifiers before, during, and after procedures. Premature infants have a greater sensitivity to pain than term infants.
  18. The recommended light (<60 fc) and sound standards (<50 dB) decrease hearing loss and poor developmental outcome in critically ill infants.
  19. Hearing deficit is the most common sensory deficit in newborns.
  20. Fetal abnormalities and congenital malformations remain the most common causes of fetal death.
  21. The use of waterless, alcohol-based hand gels reduces infection rates and maintains better skin integrity.
  22. Retinopathy of prematurity is responsible for more blindness among children in the United States than all other causes combined.
  23. Catch-up growth may be associated with an increased risk of childhood obesity.
  24. Proper positioning will prevent infants from developing positional deformities of the cranium, torso, and pelvis. These deformities interfere and delay subsequent development. Infants cannot easily move around. Pay attention to their position.
  25. The absence of a murmur in the neonatal period does not rule out congenital heart disease. An abnormal electrocardiograph in the newborn period warrants a cardiology evaluation.
  26. Maintaining patency of the ductus arteriosus is important in both severe right and left heart obstructive lesions. The physiologic effects and clinical manifestations of certain left-sided obstructive lesions (i.e., coarctation of the aorta) may not be apparent until after the ductus arteriosus closes.
  27. The most common cyanotic congenital heart lesion in the newborn period is d-transposition of the great vessels. Tetralogy of Fallot is the most common cyanotic lesion presenting outside the newborn period.
  28. The physical examination is still the most important procedure in making a diagnosis of congenital heart disease, although the echocardiogram will confirm the diagnosis. If a diagnosis of congenital heart disease is made, look for other anatomic lesions and consider the possibility of genetic and/or chromosomal abnormalities as well.
  29. In neonates with visible midline lumbosacral lesions (e.g., sacral pits, hypertrichosis, lipomas), imaging of the spine should be performed to search for occult spinal dysraphism.
  30. Hemangiomas in a “beard distribution” may be associated with internal airway hemangiomas. Certain neonatal malignancies can mimic the appearance of a “congenital hemangioma.”
  31. Premature infants born before 34 weeks’ gestation are at increased risk for transepidermal water loss. They are also at increased risk for toxic side effects of topically applied substances.
  32. If you strongly suspect an inborn error of metabolism, you should make the baby NPO (fed nothing by mouth) and give nutritional support with sufficient glucose to keep the baby anabolic.
  33. The most common cause of hypercalcemia during the neonatal period is excessive administration of calcium. The most common cause of hypermagnesemia during the newborn period is excessive maternal administration of magnesium.
  34. Treatment for congenital hypothyroidism should begin as soon as possible after birth to prevent neurologic impairment. The in utero effects of hypothyroidism are variable and may have severe adverse consequences, even with early treatment. Early neonatal screening is therefore essential for optimal outcome.
  35. The most common cause of congenital adrenal hyperplasia and sexual ambiguity at birth is 21-hydroxylase deficiency.
  36. Many of the diseases screened for at birth with expanded neonatal screening can be treated with dietary alteration with good outcome. In addition, sudden death can be avoided by knowing the presence of metabolic abnormalities such as medium- or long-chain fatty acid oxidation deficiencies in some infants.
  37. Ninety-seven percent of infants will void during the first day of life and 100% by 48 hours of age. Any infant who fails to pass urine by this time should be evaluated.
  38. A neonate requires approximately 4-8 mg/kg/min of glucose for maintenance of blood glucose levels. Under certain stress conditions, even higher rates may be necessary.
  39. Because urine output is so low and insensible water loss is high, it is exceedingly rare for a neonate to need supplemental sodium on the first day of life; early administration of sodium may actually result in hypernatremia.
  40. An infant cannot overcorrect for a metabolic acid-base disorder. In examining a blood gas result, the primary disturbance is always defined by the pH. A pH below 7.35 means that the primary disturbance is an acidosis (metabolic or respiratory), whereas a pH above 7.45 indicates that the primary disorder is an alkalosis. One cannot have, for example, a compensatory respiratory alkalosis that elevates a pH above 7.45 in response to metabolic acidosis.
  41. At term, about 40% of amniotic fluid comes from the fetal urinary tract. The remainder comes from the placenta and the lung.
  42. The serum creatinine level at the time of birth reflects the mother’s renal status, not that of the neonate. After 24-48 hours, the creatinine level is a reflection of the neonatal kidney function.
  43. Neonatal polyuria always reflects either an abnormality in renal function or excessive administration of free water to the infant.
  44. Although neonates tend to run higher serum potassium levels than older children or adults, iatrogenically induced hyperkalemia is one of the most common safety errors in the NICU and is a life-threatening emergency.
  45. In a male infant, the presence of hydronephrosis should be considered diagnostic for posterior urethral valves until proven otherwise. Posterior urethral valves are virtually never seen in a female infant.
  46. Hypertension in the low-birth-weight patient is most commonly caused by either an umbilical artery catheter or volume changes in the intravascular space associated with chronic disease states such as bronchopulmonary dysplasia.
  47. Peripheral eosinophilia is extremely common in the growing premature infant. It should not be considered an indicator of allergic gastrointestinal disease in an infant without other features to suggest such a diagnosis.
  48. The ophthalmologic examination is an extremely useful adjunct in the evaluation of the infant with cholestatic jaundice to examine for evidence of congenital infection or genetic etiology.
  49. Significant hepatic synthetic dysfunction that is disproportionate to the degree of transaminase elevation should lead to serious consideration of underlying metabolic disease (e.g., galactosemia, neonatal iron storage disease, tyrosinemia).
  50. Inadequate caloric intake continues to be the most common cause of failure to thrive for the infant recovering from a complicated neonatal medical course.
  51. For an infant needing a very high calorie formula, the use of additional carbohydrate to increase calories can be associated with diarrhea; the use of additional fat calories may be associated with recurrent emesis.
  52. Bloody diarrhea is the hallmark of colitis (e.g., allergic colitis, infection, Hirschsprung enterocolitis). Rectal bleeding without diarrhea should lead to the consideration of a focal source of bleeding (e.g., localized ulceration, arteriovenous malformation).
  53. Cholestatic jaundice associations include:
  • Cholestatic jaundice and a murmur: Think Alagille syndrome.
  • Cholestatic jaundice and ascites: Think metabolic etiologies of hepatic failure and spontaneous perforation of the bile duct.
  • Cholestatic jaundice and sepsis: Think urinary infection or metabolic disease, especially galactosemia.
  • Cholestatic jaundice with low gamma-glutamyl transferase: Think bile salt transport defects.
  1. Patchy alternations in skin pigmentation in females suggest the possibility of genetic mosaicism or X-linked disorders that result from differential lyonization.
  2. Thumb and radial ray abnormalities with or without café-au-lait spots may be the first indication of Fanconi anemia, a condition that may ultimately require carefully timed bone marrow transplant. The condition is autosomal recessive and more common in Jewish families.
  3. Half of all babies diagnosed with nonsyndromic deafness have autosomal mutations in connexin 26 with a 25% risk of recurrence in future siblings.
  4. All genetic problems in the child are not necessarily inherited from the parents. Many genetic problems are de novo, or new, to the child and suggest a low risk of recurrence for future pregnancies. However, such genetic problems can be passed on to the children of the child with the de novo mutation.
  5. Although the risk of Down syndrome is highest in mothers above the age of 35 years, the majority of cases occur in women below age 35, since they have the majority of pregnancies.
  6. Most deaths from Potter’s syndrome are due to lung hypoplasia, even though the primary disorder evolves from the genitourinary tract. The lung needs adequate amniotic fluid production to develop normally in utero.
  7. FISH testing is most helpful for disorders that emerge from the subtelomeric ends of the chromosomes, where there is great genetic density that may not be resolved by standard genetic testing.
  8. Minor chromosomal abnormalities are quite common, affecting nearly one in seven infants.
  9. The most common cause of anemia in the newborn is excessive blood drawing.
  10. Whereas Rh isoimmunization usually occurs in a second pregnancy, neonatal alloimmune thrombocytopenia may occur in the first.
  11. Neonates should always be transfused with cytomegalovirus (CMV)-negative, irradiated, leukocyte-depleted blood products.
  12. Disseminated intravascular coagulation (DIC) is always pathologic and always secondary to another process. DIC will resolve when that process is treated appropriately. Neonates require higher doses of heparin to achieve therapeutic anticoagulation.
  13. The most common tumor presenting as an abdominal mass is a neuroblastoma.
  14. Universal screening for group B Streptococcus colonization is now recommended for all pregnant women.
  15. Neonatal meningitis can occur in the setting of negative blood culture results; therefore, a lumbar puncture should be strongly considered during a sepsis evaluation.
  16. Zidovudine treatment of expectant HIV-positive mothers and their infants remains the primary intervention for decreasing the risk of vertical transmission. However, additional antiretroviral agents may be indicated for infants born to mothers without antiretroviral treatment.
  17. Fluconazole prophylaxis for infants weighing less than 1000 gm has been demonstrated to decrease the incidence of candidemia in these high-risk patients.
  18. The clinician should have a high suspicion for herpes simplex virus as a causative organism in the ill-appearing neonate. A child with fever in the first 24 hours of life should be considered to have herpes infection until proven otherwise.
  19. Six weeks of ganciclovir can improve the preservation of hearing in infants with congenital CMV infection and evidence of central nervous system involvement.
  20. Eye discharges in the neonate should always be approached with great caution. What initially seems to be a simple infection may be gonococcal in etiology.
  21. Neonatal HIV infection may present in myriad ways and should always be part of the differential diagnosis when answers are not immediately forthcoming.
  22. Ampicillin and gentamicin appear to be a more effective and safer therapy for neonatal sepsis than ampicillin and cefotaxime.
  23. Observation of the newborn infant is the key to the neurologic examination. Look at the baby for at least 2 minutes before touching him or her.
  24. The grade IV hemorrhage classification may be misleading, particularly since not all grade IVs are equivalent. Hemorrhage into the substance of the brain can be small, with a relatively better prognosis, or quite large, with a guarded prognosis in terms of mortality or serious morbidity. When the size and location of the parenchymal bleed(s) are not carefully documented, misleading therapeutic decisions and prognostic statements can ensue.
  25. Clonus, one of the most common movements confused with seizures, may be initiated by stimulation or stopped by holding or repositioning an involved extremity.
  26. Neonatal seizures are a red flag for neurologic dysfunction and injury and require emergent evaluation and treatment.
  27. When evaluating a “floppy infant,” the most important single diagnostic step is to interview and carefully examine the mother.
  28. The clinician should ask whether the process causing hypotonia is central (brain-related) or peripheral (caused by lower motor unit dysfunction). Rarely, both are involved.
  29. The complex factors that result in periventricular leukomalacia (PVL) are usually operative in utero before the neonatologist ever sees the infant. Proinflammatory cytokines appear to be an important part of the pathophysiology of PVL and, ultimately, cerebral palsy.
  30. All newborn babies should be examined for evidence of hip dysplasia, spinal dysraphism, and lower and upper extremity deficiencies and/or deformities. The hip examination consists of the Ortolani, Barlow, and Galeazzi tests.
  31. The majority of club feet can be treated effectively with manipulation and casting. Treatment should begin as soon as possible after birth. Because club foot may be associated with other congenital conditions, a thorough evaluation of the entire infant is necessary.
  32. Newborn children with a bone or joint infection may present with pseudoparalysis of the affected extremity. A fever is not a prerequisite for a bone or joint infection. Treatment of joint infections requires aspiration and antibiotics.
  33. Although children may not directly recall painful experiences from their NICU stay, they may demonstrate altered behavioral states from painful experiences that were not well managed. Morphine and fentanyl appear to be equally effective for pain relief in neonates and have similar outcomes in follow-up studies.
  34. Methadone and some of the newer narcotic agonists (e.g., buprenorphine), as well as a number of other agents, appear to be optimal treatments for narcotic withdrawal in neonates. Paregoric and phenobarbital are no longer drugs of choice.
  35. If a patient is easy to oxygenate but impossible to ventilate, airway disease should be considered as the most likely pulmonary problem. If a patient is easy to ventilate but impossible to oxygenate, cyanotic congenital heart is the most likely cause for the gas exchange problem. If both oxygenation and ventilation are problems, intrinsic lung disease is the most likely problem.
  36. Airway, airway, airway-the most important aspect of neonatal resuscitation is managing the airway! Most neonates who require support in the delivery room respond to stimulation, opening the airway, and gentle ventilation with a bag and mask.
  37. Most infants with cerebral palsy do not have a history to suggest an intrapartum event as the primary cause. The use of the term asphyxia should be avoided. It is much more useful and appropriate to describe the events and symptoms and assign more definitive diagnoses.
  38. Prevention is better than rescue treatment in promoting a healthy outcome of a neonate with respiratory distress syndrome. The most studied and effective way to improve outcomes of neonates with respiratory distress syndrome is instilling surfactant into the trachea.
  39. Vigorous meconium-stained infants do not need to be intubated and suctioned in the delivery room. Those who have an initial heart rate >100 bpm, good respiratory effort, and reasonable tone will not benefit from intubation and suctioning. In fact, some vigorous infants may be injured in the process of suctioning because they are so difficult to restrain.
  40. The most studied and effective therapy for neonates with pulmonary hypertension is inhaled nitric oxide. Ventilator-induced alkalosis, bicarbonate infusions, and prostaglandin products have not been adequately studied and should be avoided. Inhaled nitric oxide does not, however, reduce the need for extracorporeal membrane oxygenation (ECMO) in neonates with congenital diaphragmatic hernia.
  41. Both intrinsic defects in the larynx or trachea and extrinsic compression of the trachea can cause airway obstruction syndrome. Lung function is normal in most of these disorders so that airway management, which relieves the obstruction, usually normalizes gas exchange.
  42. The most effective ways to avoid lung injury in neonates who require mechanical ventilation are to optimize oxygen delivery and avoid hyperoxia and hypoxia (by carefully adjusting fractional concentration of oxygen in inspired gas [FiO2] levels), to normalize functional residual capacity to prevent lung collapse (by giving surfactant to patients with respiratory distress syndrome and using end-expiratory pressure to maintain lung volume), and to avoid volutrauma (by limiting the tidal volume used to support ventilation).
  43. The type of high-frequency ventilation device may be less important than the ventilatory strategy with which it is used. If the lung is poorly inflated, a strategy of lung recruitment (increased mean airway pressure compared with that of a conventional ventilator) is appropriate. If an air leak is present or if the lung is overinflated, a strategy that minimizes intrathoracic pressure is important, and a lower mean airway pressure may be the most appropriate approach.
  44. Survival of critically ill neonates with intractable respiratory failure is better in those offered ECMO than in those receiving conventional care. ECMO is one of the few therapies shown to save the lives of critically ill neonates.
  45. The sudden infant death syndrome (SIDS) rate in the United States has dropped precipitously from about 2 deaths per 1000 births in 1992 to the present 0.75 per 1000 births. This rapid decline followed the discovery that the simple act of changing infants’ sleeping positions from the stomach to the back dramatically reduced the SIDS rate.
  46. Infants born with isolated esophageal atresia (i.e., without a distal tracheoesophageal fistula) characteristically have a very long gap between esophageal segments, such that a primary esophageal anastomosis at the initial surgical procedure is rarely possible.
  47. If a baby has an incarcerated hernia, the gonad is at even more risk for sustaining injury than the intestine. In boys, the herniated bowel compresses the delicate spermatic vessels in the inguinal canal and can render the testicle ischemic; in girls, the ovary itself-more often than the intestine-is usually the structure that is actually herniated.
  48. Bilious vomiting that develops suddenly in an otherwise healthy infant should always be considered a potential emergency due to the possibility of midgut volvulus, and an upper gastrointestinal tract contrast study must be obtained immediately to rule it out.                                                                                                       -Anand Dhoot

Source:-fetal and neonatal secrets by
Richard a polin MD
Alan r spritzer MD

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