OFFTAG

QUESTION by Fadhlin Jamil

QUESTION 1 :

1. What is neonatal jaundice (NNJ)? (2 M)

• Yellowish discolouration of skin, mucous and sclera* (*reliable site to look for
jaundice, rich in elastin which has special affinity to bilirubin)
• Clinically detectable when the serum bilirubin levels are >85 umol/L (5mg/dL)
• Term newborn
i. Hyperbilirubinaemia
1. D3-4 of life: > 6 mg/dL
2. End of first week : 2-3 mg/dL
ii. Clinical jaundice
1. >85 umol/L (5 mg/dL)

2. What are causes of NNJ ? List 5 causes (5M)
• Hemolysis due to ABO or Rh isoimmunisation, G6PD deficiency, microspherocytosis,
drugs
• Polycythemia
• Breastfeeding or breastmilk jaundice
• Gastrointestinal tract obstruction : increase in enterohepatic circulation

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• Cephalhaematoma, subaponeurotic haemorrhage

3. Lists 5 risk factors for severe NNJ (5 marks)

• Preterm infants
• Small for gestational age
• Jaundice < 24 hours of age
e
• Hypoalbuminaemia
• Hypoxic ischemic encephalopathy

4. How you approach (history and examination) of an infant with jaundice (10 marks)

• History
i. Day of life
ii. TSB on admission (any interventions/treatment done)
iii. Birth history
1. Term / preterm
2. Birthweight
3. Apgar score
4. G6PD status
5. Complication during delivery
iv. Breastfeeding history
1. Urine output
2. Appearance and frequency of stools
3. Baby’s colour and alertness and tone
4. Weight
 5. Number of feeds in the last 24 hours
6. Baby’s behavior during feeds
7. Sucking pattern during feeds
8. Length of feeds
9. End of the feed
10. Baby’s behavior after feeds
11. Any excessive weight loss
v. Mother history
1. Maternal blood group, rhesus
2. Infective screening result
3. Antenatal history
a. Chorioamnitis / risk of sepsis ( maternal
tachycardia/fever/foul smelling)
b. DM
c. Maternal genitourinary infections/ TORCHES
vi. Family history
1. NNJ/ET/G6PD
2. Consanguinity
3. Metabolic diseases
vii. Associated symptoms
1. Pale stool
2. Dark urine
3. Bleeding tendency
4. Failure to thrive
5. Prolonged jaundice
6. Abdominal distension/pain
viii. Severity
1. Kernicterus/ABE – apnea, lethargy, poor feeding, seizures
2. Liver failure – alternate periods of irritability and confusion with
drowsiness

• Physical examination
i. Vital signs
ii. General condition – observe sign bilirubin toxicity (ABE, choreoathetoid
cerebral palsy, hearing impairment and death), use BIND score
1. Presence chephalhematoma, petechial, purpura, ecchymosis
2. Dysmorphism
3. Signs of hypothyroidism
iii. Hydration status
iv. Signs of liver failure
v. Scleral icterus/ conjuctival pallor
vi. Colour of urine and stool

5. List 3 methods of detecting jaundice (3 marks)
• TSB
• Trancutaneous bilirubinometer
• Kramers rule
Regarding pathological jaundice:

1. Definition (1 Mark )
a. Jaundice occur less than 24 hours
2. Causes of pathological jaundice (3 marks)
a. ABO incompatibility
b. TORCHES infections
c. Pyruvate kinase deficiency
d. Hemolytic disorders
3. List 3 Investigations and reason to send ( 6 M)
a. Baby and mother blood group, direct coombs test – to rule out ABO incompatibility
b. Peripheral blood film – rule out hemolytic disorders , AIHA
c. TORCHES panel test – rule out TORCHES infections
d. Pyruvate kinase test

QUESTION 2

1. Total fluid requirement for premature and term baby respectively from :

– Day 0 of life until Day 5 of life? (6M)

Day of Term (TF cc/kg/d) Preterm ( TF cc/kg/d )

life
0 60 60
1 60 60
2 90 75
3 120 90
4 150 105
5 150 120

2. What is safe rate to increase feeding for premature baby? (1M)

1. (20 x weight) / 8
*20-30 mls/kg/d

3. What is contraindication to start feeding in neonate? (3M)

o Birth weight < 1 kg

o Surgical conditions in neonates – NEC, gastrochisis, omphalocoele, trachea-esophageal
fistula, intestinal atresia, malrotation, short bowel syndrome, meconium ileus
o Birth weight > 1.5 kg and anticipated to be not on significant feeds for 5 or more days

4. Calculate the total fluid for a 3 kg baby born EMLSCS at 39 weeks.

➢ Day 2 of life (1M) : (90x3= 270) / 8 : 34 cc/3 hrly

➢ Day 4 of life (1M) : (150x3= 450) / 8 : 56 cc/3hrly

➢ Day 10 of life (1M) : (150x3=450) / 8 : 56 cc/3hrly

5. Provided no significant early neonatal issues, how do u calculate feeding

to a baby of day 5 term baby at 3 kg for a day (2M)

o (150X3) / 8 : 56 cc/3hrly

QUESTION 3

4 hour of life boy was referred from maternity ward for rapid

breathing. He was delivered SVD at 42weeks. APGAR 9/10/10. On

examination he is in respiratory distress.

1. What are the signs of respiratory distress to look for in this patient?(5 M)
a. Apnea/gasping
b. cyanosis
c. Grunting
d. Nasal flaring
e. Recession
f. Tachypneic

2. List 5 differential diagnosis. (5 M )
a. Transient tachypneic of newborn
b. Congenital pneumonia
c. Hypoglycemia
d. Meconium aspiration syndrome
e. Polycythemia or anemia
f. Neonatal sepsis

3. Significant history that you want to elicit based on your differential diagnosis above. (5
Marks)
a. Birth history
i. Term/preterm? Estimated fetal weight?
ii. Amniotic fluid clear? Meconium stained?
iii. Cord clamp at many minutes of life?
iv. SVD / Caesarian delivery
b. Antenatal risk factor
i. Fetal anemia
ii. Gestational age more than or greater than 41 + 0 weeks
iii. Maternal asthma /smoking
iv. Gdm
v. Pneumonia/GBS infection
vi. Chorioamnitis

 4. What are the investigations you would like to order and reasons for it? (5 M)

a. FBC – to rule out infections
b. CRP, Lactate – to rule out sepsis
c. Dxt at 4hol – to rule out neonatal hypoglycemia
d. ABG – hypoxaemia/hypocapnia
e. Cxray – to rule out pneumonia

5. How would you manage this patient? (5 Marks)
a. Monitor vital signs
b. Regular suction
c. Keep spo2 >90%
d. Put on oxygen support/ CPAP Fio2 depending on pt condition
e. w/o respiratory distress/ apnea
f. Ix – fbc, chestxray, DXT, ABG and other investigations
g. Correct any metabolic imbalances
h. KNBM if child in worsening respi distress ( to prepare for intubation) , KIV to start
feeding if indicated
i. To start antibiotics if FBC is suggestive

QUESTION 4

1. Define clinical neonatal hypoglycemia?(1 M)

• <2.6 mmol/L after 4 hours of life

2. What are target plasma glucose in: (2M)

1. Preterm infant at 4 hours of life : keep reflo > 2.6 mmol/L

2. Term infant at 70 hours of life : keep reflo > 3.3 mmol/L, if suspected congenital
hypoglycemia/symptomatic , keep reflo > 3.9 mmol/L

3. Which group of infants are at risk of hypoglycaemia? List 5 (5M)

• Infants of diabetic mothers

• Small for gestational age infants
• Preterm infants including late preterm infants
• Macrosomic infants / large for gestational age infants >4 kg
• Ill infants
– Polycythemia
– Sepsis
– Hypothermia
– Rhesus disease

4. List 5 signs of hypoglycaemia. (5M)

• Jitteriness and irritability

• Apnea and cyanosis
 • Hypotonia and poor feeding
• Convulsions
• Floppiness or lethargy

5. A baby at 2 hours of life with DXT 2 mmol/L, was referred from maternity with

mild tachypneic RR 62 and mild SCR, how would you manage? (3M)

1. R/O other causes of tachypneic

2. IV 10% Dextrose 2-3 ml/kg bolus
a. IV Dextrose 10% drip at 60 – 90 ml/kg/d
b. Repeat BG in 30 min
c. If still hypoglycemia, increase volume by 30 ml/kg/d
d. Repeat BG in 30 min
e. If still hypoglycemia, increase concentration to D12.5 – D15%

6. A baby at 5 hours of life, brought to ED following home delivery. You noticed

child very plethoric and DXT stat 1.2mmol/l. What do you think is the cause and

how would you manage ? (4 M)

• Cause - Neonatal sepsis

• Management
o Start empirical abx (Penicillin/ampicillin and gentamicin) if early onset and take
blood c+s
o Trace blood c+s and adjust abx accordingly
o If NOG for 48 hrs, stop abx
o Duration of abx –
§ 7-10 days for pneumonia or proven neonatal sepsis
§ 14 days for GBS meningitis
§ At least 21days for gram neg meningitis
o Consider removing central lines
o Give supportive therapy
§ O2 / ventilator support
§ Inotropes support if indicated

QUESTION 5

You are a paediatric MO and receiving one referral

regarding paediatric standby for vacuum delivery in

fetal distress of baby EFW 3.1kg, liquor clear prior

to delivery. Baby born weight 4.7kg not vigorous.

1. What is your initial steps of management? (3M)

• Observe term? Tone? Breathing /crying

• Warm and maintain normal temperature
• Position airway
• Clear secretions if needed
• Dry
• stimulate

2. If your initial steps failed, what are the things

need to be consider? (2M)

• PPV
• SPO2 monitor
• Consider ECG monitor

3. What is APGAR score and how to classify it?(5M)

• Based on the resuscitation algorithm above:

1. Fill in the HR for the diamond box listed: 1.a, 1.b

and 1.c (1.5M)

• 1.a : HR below 100 bpm

• 1.b : HR below 60 bpm
• 1.c : HR below 60 bpm

2. Signs to look for in diamond box 2. (2 M)

• Labored breathing
• Persistant Cyanosis

3. Immediate measures to proceed if presence of signs as per diamond box 2 (4 Marks)

• Position and clear airway

• Spo2 monitor
• Supplemental o2 as needed
• Consider CPAP

4. List normal target pre ductal saturation for 1 min, 2min, 3min, 4min, 5min and 10 min. (6M)
 1 min 60 – 65%
2 min 65 – 70 %
3 min 70 – 75 %
4 min 75 – 80 %
5 min 80 -85 %
10 min 85 – 95%

5. How to prepare adrenaline and what dose to give

and how. (1.5 M)

1. Epinephrine 1 : 10 000 ( 0.1 g/ml)

2. 1 amp (1 : 1 000) + 10 cc syringe of NS/D10 for dilution
3. Normal saline for flushes
4. Syringes ( 1/3/5 ml or 20 – 60 ml)
5. ECG monitor with leads
6. Supplies for emergency UVC + medication

Epinephrine dosage

Venous : 0.1 – 0.3 ml/kg in 1:10 000 + 1-3 ml of NS sterile

ETT : 0.5 – 1 ml/kg in 1:10 000 + 0.5 – 1 ml NS

Question 6

1) Below is ABG of a 10 hour old 30 weeks gestation infant.

• PH 7.2 , CO2 70 mmHg, O2 40 mmHg, BE -4

mmol/L HcO3 20 mmol/L

i. Interpret the ABG above (1M)

• Mixed repiratory and metabolic acidosis

ii. Name a differential diagnosis (1 M)

• Respiratory distress syndrome

iii. What is next appropiate therapy (1M)

• Give ventilation assistance, intubate

Question 6

2. A day 6 of life was brought in collapse state and required CPR in Emergency Department. Post
resucitation following stabilization ABG showed pH 7.0, Co2 17 mmHg, O2 40 mmHg, BE -10 mmol/L,
Hco3 8 mmol/L.

i. Interpret the ABG above (1 M)

• Metabolic acidosis

ii. Name 3 differential diagnosis and

appropriate therapy (6 M)

• Septicaemia – antibiotic infusion, rehydration

• Hypoxia – o2 support , chest xray
• Hypotension – inotropes infusion/hydrate
• Hyperkalemia – lytic cocktail

Thank you