NEONATOLOGY MA.

CATHERINE DONES, MD, DPPS

Rapid assessment a. Was the baby born after a
of every newborn full term gestation?
should be done to
ascertain the need b. Is the peritoneal fluid clear
of meconium?
for resuscitation.
The following c. Is the baby breathing or
questions may help crying?
with the said
assessment, d. Does the baby have good
except? muscle tone?
Rapid assessment a. Was the baby born after a
of every newborn full term gestation?
should be done to
ascertain the need b. Is the peritoneal fluid clear
of meconium?
for resuscitation.
The following c. Is the baby breathing or
questions may help crying?
with the said
assessment, d. Does the baby have good
except? muscle tone?
QUESTIONS FOR RAPID ASSESSMENT OF NEWBORNS
v Was as the baby born after a full term gestation?
v Is the amniotic fluid clear of meconium and evidence of infection?
vIs the baby breathing or crying?
v Does the baby have good muscle tone?
a. Suction meconium stained secretions
A live term baby
boy was
delivered via
b. Give vitamin A 0.5mg IM
NSD under your
c. Thermoregulate at temperature of
service. As the
36.5 to 37.5C attending
physician, you
d. None of the above will order the
following, except
a. Suction meconium stained secretions
A live term baby
boy was
delivered via
b. Give vitamin A 0.5mg IM
NSD under your
c. Thermoregulate at temperature
service. As the
of 36.5 to 37.5C attending
physician, you
d. None of the above will order the
following, except
NEWBORN CARE
v Suction secretions (thru ET if with vNewborn Screening
thickly meconium stained AF)
vAseptic cord care
vVitamin K 1 mg IM (term) or 0.5mg
IM (preterm) vThermoregulate at 36.5 to 37.5C

vOphthalmic ointment OU vMonitor VS q15 minutes until stable

vHepatitis B vaccine IM vEncourage breastfeeding

vBCG vaccine intradermally vRoom-in with mother once stable

 You were called to the
operating room to
attend to a delivery.
a. 6 Mother had a bit of
trouble giving birth.
After 20hours of labor,
b. 7 a stat caesarian section
was performed. Mother
gave birth to a baby
c. 8 boy. He was noted to
have acrocyanosis,
heart rate of 113bpm,
d. 9 was crying, active and
grimaces to
stimulation. APGAR
score is
 You were called to the
operating room to
attend to a delivery.
a. 6 Mother had a bit of
trouble giving birth.
After 20hours of labor,
b. 7 a stat caesarian section
was performed. Mother
gave birth to a baby
c. 8 boy. He was noted to
have acrocyanosis,
heart rate of 113bpm,
d. 9 was crying, active and
grimaces to
stimulation. APGAR
score is
APGAR SCORE
EVALUATION 0 1 2
Appearance Blue Pale, blue extremities pink
COLOR
Pulse Rate 0 <100/min >100/min
HEART RATE
Grimace None Facial grimace Active withdrawal
REFLEX IRRITABILITY
Activity None Weak, passive Active
TONE
Respiration None Irregular, shallow, gasps Crying
 WHAT YOU NEED TO KNOW ABOUT
APGAR SCORING SYSTEM
ü - APGAR scores are routinely assessed at 1 and 5
minutes, and every 5 minutes during resuscitation
ü - 1-minute score: events during labor and delivery
ü - 5-minute score: response to therapy
a. Lanugo Physical
maturity
b. Plantar surface parameters in
the Ballard
c. Square window Scoring includes
the following,
d. Genitalia except
a. Lanugo Physical
maturity
b. Plantar surface parameters in
the Ballard
c. Square window Scoring includes
the following,
d. Genitalia except
❌

BALLARD
✅
SCORE
✅ CHART
✅
As part of the Ballard
Score, assessment of a. Square window
the newborn’s
neuromuscular activity b. Popliteal angle
should be done.
Drawing the arm
across the chest c. Arm recoil
toward the newborn’s
opposite shoulder until d. Scarf sign
resistance is met
would elicit what?
As part of the Ballard
Score, assessment of a. Square window
the newborn’s
neuromuscular activity b. Popliteal angle
should be done.
Drawing the arm
across the chest c. Arm recoil
toward the newborn’s
opposite shoulder until d. Scarf sign
resistance is met
would elicit what?
BALLARD
SCORE
CHART
- Draw an arm
across the chest
toward the
newborn’s
opposite shoulder
until resistance is
met
- PRETERM: cross the
midline of chest
- TERM: not cross
the midline
SCARF SIGN
 - Gentle flexion of the
newborn’s hand toward the
ventral arm until resistance is
felt
- The angle formed at wrist is
measured

SQUARE WINDOW
- Flexion of the
newborn’s thigh on
the abdomen and
chest and extend
the lower leg till
resistance is met.
- Angle formed is
measured.

POPLITEAL ANGLE
 - Hold newborn’s arms
flexed and bent at
elbows
- Hold for 5 seconds
then release
- PRETERM: recoil
rapidly, form angle
<90 deg
- TERM: slower recoil,
angle >90deg

ARM RECOIL
A 3 day old baby was brought
to your clinic for consult. a. Salmon patch
Mother was worried of the
rashes on the baby, which
became apparent on the b. Erythema toxicum
second day of life. These
rashes are small, firm, yellow-
white, 1-2mm papules or c. Cutis marmorata
pustules with on erythematous
base, seen on the trunk, face,
extremities. If microscopically d. Transient pustular
analyzed, they consist of melanosis
eosinophils. What are these?
A 3 day old baby was brought
to your clinic for consult. a. Salmon patch
Mother was worried of the
rashes on the baby, which
became apparent on the b. Erythema toxicum
second day of life. These
rashes are small, firm, yellow-
white, 1-2mm papules or c. Cutis marmorata
pustules with an erythematous
base, seen on the trunk, face,
extremities. If microscopically d. Transient pustular
analyzed, they consist of melanosis
eosinophils. What are these?
- Frequently referred
as newborn “pink”
rash
- Firm, yellow-white
papules/pustules
with erythematous
base
- Peaks on 2nd day of
life
- Begin on the face,
spread to trunk and
limbs
- Contains eosinophils
- No treatment
required
ERYTHEMA TOXICUM
- Also known as
“stork bites”
- Pale, pink vascular
macules
- On nuchal area,
glabella, eyelids
- Small blood vessels
(capillaries) visible
through the skin
- Fades as infants grow

SALMON PATCH
- Lacy, reticulated,
vascular, reddish
or bluish patterns
- Appear over most
of the body when
baby is cooled/
temperature of
environment
suddenly falls

CUTIS MARMORATA
- Non-erythematous
pustules TRANSIENT PUSTULAR
- Have milky,
purulent exudate
MELANOSIS
- White scaled or
flaking epidermis
around perimeter
- Seen on chin, neck,
chest, back and
buttocks
TRANSIENT PUSTULAR
MELANOSIS
A newborn infant has blue-gray pigmented lesion on the sacral
area. It is clearly demarcated and does not fade into the
surrounding skin. What would be your diagnosis?

a. Mongolian spots

b. Café au lait spots

c. Hemangioma

d. Harlequin color change

A newborn infant has blue-gray pigmented lesion on the sacral
area. It is clearly demarcated and does not fade into the
surrounding skin. What would be your diagnosis?

a. Mongolian spots

b. Café au lait spots

c. Hemangioma

d. Harlequin color change

- Blue to slate-gray
macules
- On presacral,
back, posterior
thigh
- Arrested
melanocytes
- Fade over first
years
- Differential: child
abuse
MONGOLIAN SPOTS
- Permanent
patches of
pigmentation
- Increased amount
of melanin in both
melanocytes and
epidermal cells
- Presence of 6 or
more, consider
Neurofibromatosis

CAFÉ AU LAIT SPOTS

- SUPERFICIAL :
bright red,
protuberant,
sharply
demarcated, on
face, scalp, back
anterior chest,
Involute by 5 to 9
yrs of age

- DEEPER: bluish hue,

firm, cystic, less
likely to regress,
treated by steroids
or laser
HEMANGIOMA
- Sharp
demarcation in
color between one
side of the body
and the other
- Bisects the body
down the middle
- Involve face and
trunk
- Due to immaturity
of nervous system
HARLEQUIN COLOR CHANGE
A newborn was rushed
to the emergency room.
Mother had given birth a. Harlequin color change
at the tricycle while on
their way to the b. Erythema toxicum
hospital. Upon
examination of the
newborn, she was noted c. Cutis marmorata
to have lacy, reticulated
pattern of rash on the
chest and extremities. d. Mongolian spots
This is
A newborn was rushed
to the emergency room.
Mother had given birth a. Harlequin color change
at the tricycle while on
their way to the b. Erythema toxicum
hospital. Upon
examination of the
newborn, she was noted c. Cutis marmorata
to have lacy, reticulated
pattern of rash on the
chest and extremities. d. Mongolian spots
This is
- Lacy, reticulated
vascular, reddish
or bluish patters
- Appear over most
of the body when
baby is cooled/
temperature of
environment
suddenly drops

CUTIS MARMORATA
True of lanugo, except
a. Fine, soft, immature hair

b. Covers skin, except palms and soles

c. Replaces vellous hair

d. In premature infants
True of lanugo, except
a. Fine, soft, immature hair

b. Covers skin, except palms and soles

c. Replaces vellous hair

d. In premature infants
- Fine, soft immature
hair
- Covers whole skin
except palms, soles
- Replaced by vellous
hair (which is then
replaced by adult
hair)
- Seen among
preterms

LANUGO
 a. Linear fracture
As you made rounds at the
nursery, you noticed that a
12 hour old newborn has b. Caput succedaneum
nontender swelling of the
head. On further inspection, c. Cephalhematoma
you noted that it does not
cross the suture line. What
is your initial assessment? d. Depressed fracture
 a. Linear fracture
As you made rounds at the
nursery, you noticed that a
12 hour old newborn has b. Caput succedaneum
nontender swelling of the
head. On further inspection, c. Cephalhematoma
you noted that it does not
cross the suture line. What
is your initial assessment? d. Depressed fracture
CAPUT SUCCEDANEUM VS CEPHALOHEMATOMA
CAPUT SUCCEDANEUM - Diffuse edematous swelling of
soft tissues of scalp
- Crosses suture lines
CEPHALHEMATOMA - Subperiosteal hemorrhage
- Does NOT cross suture lines
- Disappears in first few days
- May lead to molding for
weeks
- May have underlying linear
fractures
- Resolve in 2 wks to 3 mos
- May calcify
- Jaundice possible
SKULL FRACTURES
• in utero from pressure against bones or forceps
• Most common: Linear

Types:
1. LINEAR – no symptoms and no treatment
2. DEPRESSED – elevate to prevent cortical injury
 a. 5%

b. 10%
Weight loss among term
newborns in their first 10
days of life c. 15%

d. 20%
 a. 5%

b. 10%
Weight loss among term
newborns in their first 10
days of life c. 15%

d. 20%
PHYSIOLOGIC PROCESSES IN NEWBORN
TERM PRETERM
ANEMIA 6 -12 weeks 5 – 10 weeks
WEIGHT LOSS (10%) First 10 days 14 – 21 days
JAUNDICE 3 -4 days 5 - 7 days
PASSAGE OF MECONIUM 0 – 48 hours
PASSAGE OF URINE 0 -24 hours: 95%
2 day old infant is
noted to be jaundiced. a. Physiologic jaundice
He is nursing and
stooling well. Indirect
bilirubin is b. Pathologic jaundice
11.2mg/dL; direct is
0.4mg/dL. Physical
exam is unremarkable c. both
except for visible
jaundice. Your
consideration would d. neither
be
2 day old infant is
noted to be jaundiced.
He is nursing and a. Physiologic jaundice
stooling well. Indirect
bilirubin is b. Pathologic jaundice
11.2mg/dL; direct is
0.4mg/dL. Physical
exam is unremarkable c. both
except for visible
jaundice. Your d. neither
consideration would
be
PHYSIOLOGIC VERSUS PATHOLOGIC JAUNDICE
PHYSIOLOGIC JAUNDICE PATHOLOGIC JAUNDICE
Appears on 2nd to 3rd day of life (term) First 24 hours of life
Disappears by 5th day of life (term) Variable
Peaks at Second to third day of life Variable
Peak bilirubin level <13mg/dL (term) Unlimited
Rate of bilirubin rise <5mg/dL/day >5mg/dL/day
Ø Appears on the first day of life
Ø Bilirubin rises >5mg/dL/day
Ø Indirect Bilirubin >13mg/dL in term infant
Ø Direct bilirubin >2mg/dL at any time

WHEN IS JAUNDICE NOT

PHYSIOLOGIC
Characteristic of pathologic jaundice

a. Onset of jaundice: 48th hour of life

b. TSB rate is increased at 0.5mg/dL/hr

c. both

d. neither
Characteristic of pathologic jaundice

a. Onset of jaundice: 48th hour of life

b. TSB rate is increased at 0.5mg/dL/hr

c. both

d. neither
PHYSIOLOGIC VERSUS PATHOLOGIC JAUNDICE
PHYSIOLOGIC JAUNDICE PATHOLOGIC JAUNDICE
Appears on 2nd to 3rd day of life (term) First 24 hours of life
Disappears by 5th day of life (term) Variable
Peaks at Second to third day of life Variable
Peak bilirubin level <13mg/dL (term) Unlimited
Rate of bilirubin rise <5mg/dL/day >5mg/dL/day
Breastmilk jaundice pertains to
a. Decreased milk intake leading to increased enterohepatic
circulation
b. Breastfeeding should not be stopped. Fluid and caloric
supplements must be provided
c. If breastfeeding is discontinued, there is rapid decrease in
bilirubin within 24 hrs
d.Bilirubin return to normal by 4 to 12 weeks
Breastmilk jaundice pertains to
a. Decreased milk intake leading to increased enterohepatic
circulation
b. Breastfeeding should not be stopped. Fluid and caloric
supplements must be provided
c. If breastfeeding is discontinued, there is rapid decrease in
bilirubin within 24 hrs
d.Bilirubin return to normal by 4 to 12 weeks
BREASTFEEDING JAUNDICE VS BREASTMILK
JAUNDICE
BREASTFEEDING JAUNDICE BREASTMILK JAUNDICE
ØUsually among first time breastfeeding ØIn 2nd week of life
moms
ØFrom glucuronidase in breast milk
ØFirst days of life
Ø Diagnosis and treatment: phototherapy if
Ø baby not nursing well, becomes needed
dehydrated – lack of calories
ØJaundice and bilirubin decrease in 48 hrs
Ø Treatment: after breastfeeding is stopped
Ølactation consult
Ø rehydrate
ØMay safely breastfed, once levels
decreased after phototherapy
ØBilirubin returns to normal 4 to 12 wks
A newborn was referred a. Indirect hyperbilirubinemia,
to your clinic for
persistent jaundice. Coombs +
Child is mother’s
firstborn. PE findings are b. Direct hyperbilirubinemia,
normal, except from Coombs -
icteric sclerae and
jaundiced skin. Prenatal c. Indirect hyperbilirubinemia,
and maternal history Coombs -
unremarkable. Mother is
Rh negative, baby is Rh d. Direct hyperbilirubinemia,
positive. Expected Coombs +
laboratory results are
A newborn was referred a. Indirect hyperbilirubinemia,
to your clinic for
persistent jaundice. Coombs +
Child is mother’s
firstborn. PE findings are b. Direct hyperbilirubinemia,
normal, except from Coombs -
icteric sclerae and
jaundiced skin. Prenatal c. Indirect hyperbilirubinemia,
and maternal history Coombs -
unremarkable. Mother is
Rh negative, baby is Rh d. Direct hyperbilirubinemia,
positive. Expected Coombs +
laboratory results are
JAUNDICE ALGORITHM
a. Photoisomerization: unconjugated bilirubin converted to polar isomer and
excreted in bile
b. Structural isomerization: cyclization of bilirubin to lumirubin, excreted in bile and
urine without conjugation
c. Photooxidation: converts bilirubin to small, polar products and excreted in urine

d. All of the above

Mechanism of action with which phototherapy

works
a. Photoisomerization: unconjugated bilirubin converted to polar isomer and
excreted in bile
b. Structural isomerization: cyclization of bilirubin to lumirubin, excreted in bile and
urine without conjugation
c. Photooxidation: converts bilirubin to small; polar products and excreted in urine

d. All of the above

Mechanism of action with which phototherapy

works
MECHANISM OF ACTION OF PHOTOTHERAPY
Mechanism Processes Excretion
PHOTOISOMERIZATION Natural isomer of unconjugated Excreted in bile
bilirubin converted to less toxic
polar isomer
STRUCTURAL ISOMERIZATION Most important pathway Excreted in bile and urine without
intramolecular cyclization of conjugation
bilirubin to lumirubin
PHOTOOXIDATION Least important Excreted in urine
Converts bilirubin to small polar
products
 a. An additional 10-20% must be added to the
As an esteemed newborn’s weight, in getting the TFR, to
neonatologist, you were maintain normothermia and prevent
asked by the hospital dehydration
administrator if you can b. Tungsten halide lamps are not
help train the NICU nurses effective
on how to facilitate
phototherapy. Which of the c. Optimal wavelength: 100-200nM
following would be one of
the important points of
discussion? d. Red man syndrome is one side effect
 a. An additional 10-20% must be added to
As an esteemed the newborn’s weight, in getting the TFR, to
neonatologist, you were maintain normothermia and prevent
asked by the hospital dehydration
administrator if you can b. Tungsten halide lamps are not
help train the NICU nurses effective
on how to facilitate
phototherapy. Which of the c. Optimal wavelength: 100-200nM
following would be one of
the important points of
discussion? d. Red man syndrome is one side effect
PHOTOTHERAPY
TECHNIQUES SIDE EFFECTS
Ø weight + 10-20% = TFR, prevent Ø increased insensible water loss (term
dehydration and maintain normothermia 40% and preterm 80%)
ØMaximize skin surface area exposed to ØDiarrhea
light
ØHypocalcemia
ØSpecial blue lights and Tungsten halide
lamps are effective ØRetinal damage

ØOptimal wavelength: 475 to 500nM ØBronze baby syndrome

ØRebound phototherapy
You have been asked to a. Stimulate the baby
attend to a normal
spontaneous delivery of
a G4P3 (3003) mother at b. Suction secretions
39 wks gestation.
However during delivery
amniotic fluid was noted
to be thickly meconium
c. Make the baby cry
stained. What is the
most important step that
should be done? d. All of the above
You have been asked to a. Stimulate the baby
attend to a normal
spontaneous delivery of
a G4P3 (3003) mother at b. Suction secretions
39 wks gestation.
However during delivery
amniotic fluid was noted
to be thickly meconium
c. Make the baby cry
stained. What is the
most important step that
should be done? d. All of the above
Despite vigorous suctioning,
the newborn was observed
to have tachypnea and
retractions. Meconium
aspiration syndrome is
considered. The parents are
having queries about their
baby’s condition. They are
asking what a meconium is.
You’d tell them?
a. Passed due to hypoxia and fetal
distress
b. Aspirated in utero
c. Aspirated on first postnatal
breath
d. All of the above
Despite vigorous suctioning,
the newborn was observed
to have tachypnea and
retractions. Meconium
aspiration syndrome is
considered. The parents are
having queries about their
baby’s condition. They are
asking what a meconium is.
You’d tell them
a. Passed due to hypoxia and fetal
distress
b. Aspirated in utero
c. Aspirated on first postnatal
breath
d. All of the above
The relatives a. Pneumothorax
also asked you if
there would be b. Persistent pulmonary
any hypertension
complications
that should be c. Pneumomediastinum

expected. You
would cite the d. None of the above
following, except
The relatives a. Pneumothorax
also asked you if
there would be b. Persistent pulmonary
any hypertension
complications
that should be c. Pneumomediastinum

expected. You
would cite the d. None of the above
following, except
MECONIUM ASPIRATION SYNDROME
§ meconium is passed as result of hypoxia and fetal distress ⇢ aspirated in utero or
at first postnatal breath⇢ airway obstruction and pneumonitis ⇢ failure and
pulmonary hypertension
§ CXR: patchy infiltrates, increased AP diameter, flattening of diaphragm
§ Complications: pneumothorax, pneumomediastinum, persistent pulmonary
hypertension
§ Treatment: positive pressure ventilation
§ Prevention: endotracheal intubation, airway suction of depressed infants with thick
meconium
On the 5 th day of life, patient deteriorated. Vital signs revealed RR of 78/min
and HR of 48/min. Positive pressure ventilation provided, but did not provide
improvement. Chest compressions are then started. Which is true of
compressions?

a. Indicated when HR remains <40/min despite 30 seconds of

effective positive pressure ventilation
b. 2 finger technique preferred

c. Thumb technique preferred

d. 120 compressions per minute should be done

On the 5 th day of life, patient deteriorated. Vital sjgns revealed RR of 78/min
and HR of 48/min. Positive pressure ventilation provided, but did not provide
improvement. Chest compressions are then started. Which is true of
compressions?

a. Indicated when HR remains <40/min despite 30 seconds of

effective positive pressure ventilation
b. 2 finger technique preferred

c. Thumb technique preferred

d. 120 compressions per minute should be done

CHEST COMPRESSIONS - NEONATE
FOR HR <60 BPM DESPITE 30SECONDS EFFECTIVE PPV
Ø compress the heart against the spine --Increase intrathoracic pressure --Circulate
blood to the vital organs
Ø2 techniques: thumb (more preferred) and 2 finger
Ø Run fingers along the lower edge of ribcage and locate the xyphoid. Place thumb
or 2 fingers on sternum, above xyphoid
ØRATE: 30 breaths/min. 90 compressions/min. 20 events per minute. 1 cycle: 3
compressions and 1 breath takes 2 seconds.
Ø”One and Two and three and Breathe”
a. Discontinue compressions, but continue ventilation at 40-60 per minute

b. Discontinue compressions, gradually discontinue ventilation

c. Intubate newborn and give epinephrine

d. Continue compressions

After 30 seconds of chest compressions and ventilation, heart

rate of the patient was 36 per minute. What would you do?
a. Discontinue compressions, but continue ventilation at 40-60 per minute

b. Discontinue compressions, gradually discontinue ventilation

c. Intubate newborn and give epinephrine

d. Continue compressions

After 30 seconds of chest compressions and ventilation, heart

rate of the patient was 36 per minute. What would you do?
AFTER 30 SECONDS OF CHEST COMPRESSIONS
AND VENTILATION
GREATER THAN 60 BPM
ØDiscontinue compressions and continue ventilation at 40 to 60 breaths per minute
GREATER THAN 100 BPM
Ø discontinue compressions and gradually discontinue ventilation if the newborn is
breathing spontaneously
LESS THAN 60 BPM
Ø intubate, give epinephrine
 a. Tip to lip measurement: add 4 to
newborn’s weight
You have decided to
intubate the patient. What
would be the indications b. Absence of vapor in the ET tube
that you have already at exhalation
placed the endotracheal
tube correctly? c. Chest movement with each breath

d. All of the above

 a. Tip to lip measurement: add 4 to
newborn’s weight
You have decided to
intubate the patient. What
would be the indications b. Absence of vapor in the ET tube
that you have already at exhalation
placed the endotracheal
tube correctly? c. Chest movement with each
breath
d. All of the above
CORRECT PLACEMENT OF ET TUBE IS INDICATED BY
ü direct visualization of tube passing between the vocal cords
üImproved vital signs (HR, color, activity)
üBreath sounds over both lung fields, none on the stomach
üNO gastric distention with ventilation
üVapor in tube at exhalation
üChest movement with each breath
üTip to lip measurement: Newborn’s weight in kg +6
üChest xray confirmation
The neonate was 39 weeks AOG and was 3.6kg in weight.
What endotracheal tube size should be utilized?

a. 2.5 b. 3.0 c. 3.5 d. 4.0

The neonate was 39 weeks AOG and was 3.6kg in weight.
What endotracheal tube size should be utilized?

a. 2.5 b. 3.0 c. 3.5 d. 4.0

NEONATAL ENDOTRACHEAL TUBE SIZE

TUBE SIZE BIRTHWEIGHT GESTATIONAL AGE

4.0 >3kg Term
3.5 2-3kg 34-38 wks
3.0 1-2kg 28-34 wks
2.5 <1kg <28 wks
With heart rate a. Can be given at a dose of
lower than 60 per 0.1ml/kg via ET tube
minute,
epinephrine is b. Given thru slow IV push
indicated. Which
statement c. ET route has unreliable
regarding absorption
epinephrine
administration is d. All of the above
true?
With heart rate a. Can be given at a dose of
lower than 60 per 0.1ml/kg via ET tube
minute,
epinephrine is b. Given thru slow IV push
indicated. Which
statement c. ET route has unreliable
regarding absorption
epinephrine
administration is d. All of the above
true?
USE OF EPINEPHRINE IN NEONATAL RESUSCITATION
Ø CONCENTRATION: 1:10,000 (0.1mg/ml)
ØROUTE: IV, ET may be considered while IV access still not done
ØDOSE: 0.1 to 0.3 ml/kg for IV ( 0.3 to 1ml/kg for ET)
ØPREP: 1:10,000 solution
ØADMINISTRATION RATE: rapid

***ET is faster than umbicath, but with unreliable absorption

A type of intrauterine growth restriction in which there is early
onset, equal effect to all body parts, and poor prognosis

a. symmetric
b. asymmetric
c. unilateral
d. bilateral
A type of intrauterine growth restriction in which there is early
onset, equal effect to all body parts, and poor prognosis

a. symmetric
b. asymmetric
c. unilateral
d. bilateral
 a. symmetric

A type of intrauterine
growth restriction due to
either poor maternal b. asymmetric
nutrition or late onset of
maternal vascular disease
(eg. hypertension) c. unilateral

d. bilateral
 a. symmetric

A type of intrauterine
growth restriction due to
either poor maternal b. asymmetric
nutrition or late onset of
maternal vascular disease
(eg. hypertension) c. unilateral

d. bilateral
INTRAUTERINE GROWTH RESTRICTION
TYPE REASON MAIN ETIOLOGIES COMPLICATIONS
SYMMETRIC ü Early, in utero ü Genetic syndromes ü Etiology dependent
ü Affects growth of most organs ü Chromosomal ü Delivery of oxygen
abnormalities and nutrients to vital
ü Congenital infections organs
ü Teratogens
ü Toxins
ASYMMETRIC ü Late onset ü Uteroplacental ü Neurologic /
ü After fetal organ development insufficiency asphyxia – decreased
ü Abnormal delivery of nutritional ü due to maternal diseases delivery of oxygen to
substances and oxygen to fetus (malnutrition, cardiac and brain
renal diseases, anemia)
ü From placental dysfunction
(hypertension, autoimmune
disease, abruptio)
The following are problems among IUGR (SGA)
infants, except
a. Perinatal asphyxia

b. Polycythemia hyperviscosity

c. Hypothermia

d. Hyperglycemia
The following are problems among IUGR (SGA)
infants, except
a. Perinatal asphyxia

b. Polycythemia hyperviscosity

c. Hypothermia

d. Hyperglycemia
PROBLEMS OF IUGR (SGA) INFANTS
Ø Intrauterine fetal demise
Ø Perinatal asphyxia
Ø Hypoglycemia
Ø Polycythemia – hyperviscosity
Ø Reduced oxygen
Ø Dysmorphology
 a. Hyperparathyroidism –
True of neonatal hypocalcemia
maternal
illnesses and b. Parvovirus - hydrops
their
corresponding c. Both
effects on the
fetus d. Neither
 a. Hyperparathyroidism –
True of neonatal hypocalcemia
maternal
illnesses and b. Parvovirus - hydrops
their
corresponding c. Both
effects on the
fetus d. Neither
MATERNAL DISEASES AFFECTING THE FETUS /
NEONATE
MATERNAL DISEASE EFFECT ON FETUS/ NEONATE
E. coli, Group B strep, Listeria Sepsis
Chlamydia Pneumonia, Conjunctivitis
Neisseria Conjunctivitis
Mycobacterium tuberculosis Prematurity, fetal demise, congenital TB
Herpes simplex II Neonatal encephalitis
Parvovirus Fetal anemia, hydrops
Coxsackie virus B Myocarditis
Malaria Abortion, prematurity, IUGR
MATERNAL DISEASE AFFECTING THE FETUS / NEONATE
MATERNAL DISEASE EFFECT ON FETUS/ NEONATE
Diabetes Mellitus LGA, hypoglycemia
Graves Disease Transient neonatal thyrotoxicosis
Hyperparathyroidism Neonatal hypocalcemia
Hypertension IUGR, IUFD
Obesity Macrosomia, hypoglycemia
Phyenylketonuria Microcephaly, retardation
Sickle cell anemia IUGR, Prematurity, heart block
Conditions associated with oligohydramnios

a. Potter syndrome , TORCH

b. Prune belly syndrome, Potter syndrome
c. TORCH, Prune Belly syndrome
d. TORCH only
Conditions associated with oligohydramnios

a. Potter syndrome , TORCH

b. Prune belly syndrome, Potter syndrome
c. TORCH, Prune Belly syndrome
d. TORCH only
CONDITIONS ASSOCIATED WITH AMNIOTIC FLUID
VOLUME DISORDERS
OLIGOHYDRAMNIOS POLYHYDRAMNIOS
v IUGR v Congenital anomalies: anencephaly,
TEF, duodenal atresia, CCAM,
vFetal anomalies diaphragmatic hernia, spina bifida
vTwin-twin transfusion v Syndromes: TORCH, Trisomy 18/21,
vAmniotic fluid leak Hydrops fetalis, Achondroplasia, multiple
congenital anomaly
vRenal agenesis (Potter)
v Urethral atresia
vPrune- Belly syndrome
vIntestinal pseudo-obstruction
 A 3 day old baby was
brought to the clinic with a. Silver nitrate
thick and purulent edema of
the eyelids and marked
chemosis. Upon further
interview of the mother, it b. Neisseria gonorrhea
was found that the newborn
was delivered at home by a
hilot and with no further c. Chlamydia
routine newborn care given.
What could have caused this d. Pseudomonas
eye infection ?
 A 3 day old baby was
brought to the clinic with a. Silver nitrate
thick and purulent edema of
the eyelids and marked
chemosis. Upon further
interview of the mother, it b. Neisseria gonorrhea
was found that the newborn
was delivered at home by a
hilot and with no further c. Chlamydia
routine newborn care given.
What could have caused this d. Pseudomonas
eye infection ?
OPHTHALMIA NEONATORUM
ETIOLOGY INCUBATION PERIOD MANIFESTATIONS
Silver Nitrate 6 to 12 hours after birth Cleared by 24 to 48 hours
Neisseria gonorrhea 2 to 5 days Serosanguinous discharge in 24 hours, thick and
purulent discharge, edema of eyelids, marked
chemosis
G/S: intracellular Gram negative diplococci
Chlamydia trachomatis 5 to 14 days Copious purulent eye discharge with tarsal
conjunctivitis
Giemsa stain: intracytoplasmic inclusions
Staphylococcus aureus Variable Similar to Chlamydia
Pseudomonas Variable From nursery, Day 5 to 18; pannus formation,
aeruginosa endophthalmitis, sepsis, shock, death
Management for ophthalmia neonatorum
caused by Chlamydia
a. Supportive only

b. Erythromycin

c. Ceftriaxone

d. Methicillin
Management for ophthalmia neonatorum
caused by Chlamydia
a. Supportive only

b. Erythromycin

c. Ceftriaxone

d. Methicillin
OPHTHALMIA NEONATORUM
ETIOLOGY MANAGEMENT
Silver Nitrate Supportive
Neisseria gonorrhea Ceftriaxone for 7 days
Saline eye irrigation
Alternative: Kanamycin IM with
Gentamycin eye ointment for 3 days
Chlamydia trachomatis Erythromycin PO for 2 weeks
Staphylococcus aureus IV methicillin
Saline irrigation
Pseudomonas Aminoglycoside IV
aeruginosa Gentamycin eye ointment
Saline irrigation
 a. Early

Type of hemorrhagic
disease of the newborn b. Classic
which is due to exclusive
breastfeeding
c. Late

d. Nonclassic
 a. Early

Type of hemorrhagic
disease of the newborn b. Classic
which is due to exclusive
breastfeeding
c. Late

d. Nonclassic
HEMORRHAGIC DISEASE OF THE NEWBORN
TYPE ONSET PREDISOPOSING CLINICAL
FACTORS MANIFESTATIONS
Early 0-24 hours Maternal intake of Serious bleeding,
anticoagulants or including intracranial
anticonvulsants hemorrhage
Classic 1-7 days No Vitamin K at birth Cutaneous or GI bleed
Late 1-3 months Exclusively
breastfeeding
Reasons why preterms have problems in
thermoregulation
a. Larger surface area

b. Low subcutaneous fat

c. Less brown fat stores

d. All of the above

Reasons why preterms have problems in
thermoregulation
a. Larger surface area

b. Low subcutaneous fat

c. Less brown fat stores

d. All of the above

PRETERM PROBLEMS IN THERMOREGULATION
Ø Larger surface area
Ø Decreased subcutaneous fat, less insulation
Ø Less well-developed brown fat stores
Ø Unable to take enough calories for use in thermogenesis
Ø Oxygen consumption limited in some infants with pulmonary problems
A 33 week newborn is
admitted at the nursery. She a. Intubate immediately
is on IV antibiotics and is
considered to have sepsis.
On her 3rd day of life, she
was referred by the nurse b. Change antibiotics
for a respiratory pause
around 20 seconds long. No
bradycardia nor oxygen c. Start aminophylline
desaturation observed.
What would be the next step d. Request for chest xray
in your management?
A 33 week newborn is
admitted at the nursery. She a. Intubate immediately
is on IV antibiotics and is
considered to have sepsis.
On her 3rd day of life, she
was referred by the nurse b. Change antibiotics
for a respiratory pause
around 20 seconds long. No
bradycardia nor oxygen c. Start aminophylline
desaturation observed.
What would be the next step d. Request for chest xray
in your management?
APNEA OF PREMATURITY
Ø Respiratory pause of >15 to 20 seconds without bradycardia or hypoxemia OR
<15 seconds with bradycardia or hypoxemia
Ø Resolves between 34 to 36 weeks AOG
ØTriggered by infection , obstruction or feeding
ØManagement:
• Xanthines (Aminophylline, theophylline)
• Head up position after feeding
a. Lecithin/ sphingomyelin ratio of more than 2
b. Excessive surfactant production
c. Decreased surface tension
d. Alveolar collapse

A preterm 28 weeks AOG was born via stat CS to a diabetic mother. Since
delivery, he was noted to have RR of 70s, with global retractions and grunting.
CXR Revealed air bronchogram. He is presently on CPAP and is closely
monitored. What would explain the neonate’s condition?
a. Lecithin/ sphingomyelin ratio of more than 2
b. Excessive surfactant production
c. Decreased surface tension
d. Alveolar collapse

A preterm 28 weeks AOG was born via stat CS to a diabetic mother. Since
delivery, he was noted to have RR of 70s, with global retractions and grunting.
CXR Revealed air bronchogram. He is presently on CPAP and is closely
monitored. What would explain the neonate’s condition?
RESPIRATORY DISTRESS SYNDROME TYPE I
q HYALINE MEMBRANE DISEASE
q Increase in incidence among preterms
q Risk factors: diabetic mothers, CS, multiple pregnancies, asphyxia
q Decreased surfactant (L/S ratio of <2), alveolar collapse, increased surface
tension, hypoxia, acidosis
q early onset of respiratory distress
qCXR: ground glass, air bronchogram
qTreatment: surfactant, antenatal steroids
A term 38 weeks AOG
a. Hyaline Membrane Disease
newborn was born via NSD.
Maternal history b. Neonatal Pneumonia
uneventful. Since delivery,
he is noted to have RR of
60 to 70, with retractions, c. Transient Tachypnea of the Newborn
but with clear breath
sounds. CXR revealed
prominent pulmonary d. Clinical Sepsis
vascular markings. On the
third day of life, condition
spontaneously resolved.
What would be your
diagnosis?
 a. Hyaline Membrane Disease
A term 38 weeks AOG
newborn was born via NSD.
Maternal history b. Neonatal Pneumonia
uneventful. Since delivery,
he is noted to have RR of
60 to 70, with retractions, c. Transient Tachypnea of the Newborn
but with clear breath
sounds. CXR revealed
prominent pulmonary d. Clinical Sepsis
vascular markings. On the
third day of life, condition
spontaneously resolved.
What would be your
diagnosis?
RESPIRATORY DISTRESS SYNDROME TYPE II
q TRANSIENT TACHYPNEA OF THE NEWBORN
q Slow absorption of fetal lung fluid resulting in decreased pulmonary compliance/
tidal volume and increased dead space
qEarly onset tachypnea, grunting, recover in 3 days
q PE: clear lungs
q CXR: prominent pulmonary vascular markings
A non-institutional borne term a. Necrotizing enterocolitis
baby was brought to the
emergency room due to
difficulty of breathing. No
relatives were present, thus
maternal history unknown. On b. Severe pneumonia
PE, patient was noted to have
RR of 68/min, with scaphoid
abdomen and presence of c. Diaphragmatic hernia
bowel sounds upon
auscultation of the chest. What
would be your impression? d. Duodenal atresia
A non-institutional borne term a. Necrotizing enterocolitis
baby was brought to the
emergency room due to
difficulty of breathing. No
relatives were present, thus
maternal history unknown. On b. Severe pneumonia
PE, patient was noted to have
RR of 68/min, with scaphoid
abdomen and presence of c. Diaphragmatic hernia
bowel sounds upon
auscultation of the chest. What
would be your impression? d. Duodenal atresia
DIAPHRAGMATIC HERNIA
§ Failure of the diaphragm to close – abdominal contents enter into chest, causing
pulmonary hypoplasia
§ Born with respiratory distress and scaphoid abdomen
§ Bowel sounds may be heard in chest
§ Confirmatory test: postnatal xray reveals bowels in chest
§ Best initial treatment: immediate intubation in delivery room followed by surgical
correction when stable
As a pediatrician, you
are required to know the a. Observe generalized
prenatal history of the calcifications
mother of the baby
which will soon be b. Presence of Hutchinson teeth
delivered. The about-to- at birth
be-mother was
diagnosed of syphilis.
The said disease was c. Have snuffles at neonatal
said to be active even period
during the course of
pregnancy. What would d. Note cataracts
you expect of the
newborn?
As a pediatrician, you
are required to know the a. Observe generalized
prenatal history of the calcifications
mother of the baby
which will soon be b. Presence of Hutchinson teeth
delivered. The about-to- at birth
be-mother was
diagnosed of syphilis.
The said disease was c. Have snuffles at neonatal
said to be active even period
during the course of
pregnancy. What would d. Note cataracts
you expect of the
newborn?
CONGENITAL SYPHILIS
o transplacental transmission during second trimester
o At risk infants must have serologic screening at delivery
o EARLY (birth to 2 months)
o Snuffles, maculopapular rash, jaundice, periostitis, osteochondritis, chorioretinitis, congenital nephrosis

o LATE (>2 years old)

o Hutchinson teeth, Clutton joints, Saber shin, saddle nose, osteochondritis, rhagades (thickening and
fissures of corner of mouth)

o Diagnosis: Treponema scrapings, IgM – FTA-ABS

o Treatment: Penicillin
EFFECTS OF MATERNAL TORCH INFECTIONS ON
NEONATES
INFECTIONS PRESENTATION
TOXOPLASMOSIS Hydrocephalus with generalized
calcifications and chorioretinitis
RUBELLA Cataract, deafness, heart defects
CMV Microcephaly with periventricular
calcifications, petechiae with
thrombocytopenia
HERPES Skin vesicles, keratoconjunctivitis, acute
meningoencephalitis
SYPHILIS Osteochondritis and periostitis, skin rash
on palms and soles, desquamating;
snuffles (mucopurulent rhinitis )