Pediatric Examination and Board Review (199 page)

Kellogg ND; Committee on Child Abuse and Neglect. American Academy of Pediatrics. The evaluation of sexual abuse in children.
Pediatrics
. 2005;116:506-512.

Reece RM, Christian CW, eds.
Child Abuse
:
Medical Diagnosis and Management
. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

Chapter 14

NEONATAL MEDICINE

CASE 111: A TERM NEONATE WITH RESPIRATORY DISTRESS

You are asked to attend the delivery of a baby weighing 3500 g who is at 40 weeks’ gestation. The mother is 35-years-old and G2P1. Delivery was by emergency cesarean delivery for fetal distress and late decelerations. Rupture of maternal membranes occurred 28 hours before delivery. Thick meconium-stained amniotic fluid was noted at that time. The mother received four doses of ampicillin before delivery. All prenatal ultrasounds were normal.

SELECT THE ONE BEST ANSWER

1.
The best initial airway management of this neonate is to

(A) suction the oropharynx and nasopharynx before delivery of the shoulders

(B) suction the oropharynx and nasopharynx after delivery

(C) immediately take the neonate to the warming table for vigorous drying before any suctioning of the airway

(D) give blow-by oxygen and observe before any suctioning of the airway

(E) not allow the vigorous neonate to cry and intubate the neonate before any airway suctioning

2.
The cesarean section delivery is uneventful. Shortly after birth, the baby has subcostal and intercostal retractions. The oxygen (O
₂
) saturation in room air is 72%. The baby is placed under a 60% O
₂
hood with improvement in O
₂
saturation to 95%. Which is the least likely diagnosis?

(A) sepsis

(B) transient tachypnea of the newborn

(C) phrenic nerve injury

(D) group B streptococcal pneumonia

(E) meconium aspiration

3.
Following the scenario in question 2, which would not be indicated at this time?

(A) chest radiograph

(B) blood culture and complete blood count (CBC) with differential leukocyte count

(C) blood glucose

(D) chest tube thoracostomy

(E) hyperoxia test

4.
Following the scenario in question 2 what should be included in the management of the patient at this time?

(A) giving nothing by mouth (NPO) and starting intravenous (IV) maintenance fluids

(B) starting antibiotics

(C) monitoring O
₂
saturation

(D) monitoring blood glucose concentration

(E) all of the above

5.
The arterial blood gas (ABG) determination on 60% O
₂
delivered by hood reveals a pH 7.35, PaO
₂
45, Po
₂
52. What is/are the likely diagnosis/diagnoses based on these ABG data and the chest radiograph seen in
Figure 111-1
?

(A) pneumonia, probably bacterial

(B) meconium aspiration pneumonitis

(C) transient tachypnea of the newborn (TTN)

(D) transposition of the great arteries

(E) A or B

FIGURE 111-1.

6.
After the blood gas result was obtained, the fraction of inspired oxygen (Fio
₂
) was increased to 1.0; the O
₂
saturation was still in the 88-92% range. The baby was intubated and mechanically ventilated with an Fio
₂
1.0, peak inspiratory pressure (PIP) 25, positive end-expiratory pressure (PEEP) 5, rate 60, I-time 0.4. The ABG values were pH 7.37, partial pressure of carbon dioxide (Pco
₂
) 40, partial pressure of oxygen (PaO
₂
) 50, mean airway pressure (MAP) 13. What other treatment do you want to initiate at this time?

(A) surfactant

(B) prostaglandins

(C) nitrous oxide

(D) furosemide

(E) dobutamine

7.
What is the most important next diagnostic test?

(A) echocardiography

(B) cardiac catheterization

(C) head ultrasound

(D) computed tomography of the chest

(E) no additional diagnostic test is needed

8.
An echocardiogram shows a bidirectional shunt at the atrial level, a tricuspid jet of 4.0, bulging of the interatrial septum toward the left side, normal valves, pulmonary veins and aorta, and good myocardial function. These findings are diagnostic of

(A) pulmonary hypertension

(B) cyanotic heart disease

(C) idiopathic hypertrophic subaortic stenosis (IHSS)

(D) congenital cardiomyopathy

(E) none of the above

9.
What factor at birth decreases the pulmonary vascular resistance?

(A) cold stimulus

(B) decrease in alveolar Po
₂

(C) increase in partial pressure of alveolar CO
₂

(D) leukotrienes

(E) mechanical distension of the lungs

10.
All of the following may play a role in the management of persistent pulmonary hypertension (PPHN) except

(A) inotropes

(B) milrinone

(C) furosemide

(D) inhaled nitric oxide (NO)

(E) sildenafil

11.
Which of the following factors can lead to pulmonary hypertension?

(A) sepsis

(B) meconium aspiration

(C) respiratory distress syndrome (RDS)

(D) diaphragmatic hernia

(E) all of the above

12.
The ventilatory settings are increased to PIP 35, PEEP 5, rate 60, Fio
₂
1.0, and I-time 0.4. The MAP is 15. The ABGs on these settings are pH 7.40, Pco
₂
38, and Pao
₂
50. What is the oxygenation index of this patient?

(A) 3%

(B) 30%

(C) 33%

(D) 53%

(E) 60%

13.
Because the PIP is 35 and the Pao
₂
is still 50, you are worried about barotrauma and change the ventilator to high-frequency oscillatory ventilation (HFOV). The ABGs on the HFOV at an Fio
₂
1.0, MAP 17, ΔP 35, Hz 10, and 20 ppm NO are pH 7.41, Pco
₂
35, and Pao
₂
200. Pre- and postductal O
₂
saturation is 100%. The baby does well for a few hours and then desaturates to the 60% range. The heart rate drops to 80 and the mean blood pressure (BP) is 28. Immediate management includes all of the following except

(A) check endotracheal tube (ET) placement

(B) check for pneumothorax

(C) give intravascular volume expansion

(D) give surfactant

(E) all of the above

14.
The patient stabilizes after an IV fluid bolus and an increase in ventilatory settings. In the next few hours, the baby is very labile and requires frequent volume pushes to keep the mean BP in the 60 mm Hg range. Dopamine is being administered at 20 μg/kg per minute. The baby desaturates when the mean BP is less than 50 mm Hg. ABG values on HFOV, Fio
₂
1.0, MAP 20, ΔP 40, Hz 10 are pH 7.45, Pco
₂
32, and Pao
₂
48. A chest radiograph shows a 10-rib expansion and no air leak. The cardiothymic shadow is normal. Management at this time could include which of the following?

(A) increase the ventilatory settings

(B) ↑NO to 40 ppm

(C) prepare for extracorporeal membrane oxygenation (ECMO)

(D) all of the above

(E) none of the above

15.
Which medication used by the mother during the last trimester of her pregnancy is most likely to cause PPHN in her newborn?

(A) phenobarbital

(B) captopril

(C) aspirin

(D) bupropion

(E) levothyroxine

ANSWERS

1.
(A)
Meconium is composed of intestinal cells, the solid components of amniotic fluid, and intestinal secretions. The neonate’s first several bowel movements are meconium. Stressors to the fetus, such as maternal preeclampsia or placental insufficiency, may cause the fetus to pass meconium in utero. Reflexively, the fetus will also make gasping movements, which may result in aspiration of the meconium. Besides decreasing the antibacterial quality of the amniotic fluid, predisposing the fetus to infection, meconium has negative effects on the fetal respiratory system. Airway obstruction by the particulate meconium, disruption of the surfactant layer, and chemical pneumonitis are all deleterious effects of meconium. Meconium staining of amniotic fluid occurs in 10-15% of deliveries. Meconium aspiration occurs in 1% of these cases. Whenever meconium is noted in amniotic fluid, whether it is thin or thick, obstetricians should suction the infant’s oropharynx and nasopharynx before delivery of the shoulders. Babies that are vigorous at birth will not benefit from intubation and suctioning.