CLIPP Cases

Case #1
What medical risks exist for the infant of an adolescent mother as compared to an infant born to a woman who
is 20 or older?
Infants born to adolescent mothers are at greater risk for lower birth weight (B).
These infants are also at greater risk for vertically acquired sexually transmitted diseases (STDs) (C)
given the higher incidence of STDs in the adolescent population.
Infants born to adolescent women also have poorer developmental outcomes (D) and increased risk of
fetal death.

Adverse Effects of Prenatal Substance Use

Tobacco

Maternal tobacco use during pregnancy increases the risk for low birth weight (A) in the fetus.
There is not a characteristic facies associated with maternal tobacco use during pregnancy.
Alcohol

There is no "safe" amount of alcohol that can be consumed during pregnancy to ensure that fetal alcohol
syndrome (B) does not occur.
Fetal alcohol syndrome is a distinct pattern of facial abnormalities, growth deficiency and evidence of
central nervous system dysfunction.
In addition to mental retardation, victims of fetal alcohol syndrome exhibit other neurobehavioral
deficits such as poor motor skills and hand-eye coordination and learning problems (i.e., difficulties with
memory, attention, and judgment).
Marijuana

Distinctive effects of marijuana have not been identified (C), but infants born to mothers who smoke
marijuana more than six times per week often have a withdrawal-like syndrome (high-pitched cry and
tremulousness) in the first days after birth.
Cocaine and Other Stimulants

These cause vasoconstriction leading to placental insufficiency and low birth weight (D).
In addition, the National Institute on Drug Abuse notes that "exposure to cocaine during fetal
development may lead to subtle, yet significant, later deficits in some children, including deficits in
some aspects of cognitive performance, information-processing, and attention to tasks -- abilities that are
important for success in school."

Small for gest age = AKA IUGR

Prenatal Lab Screening
These are usually included in the prenatal lab screening:

Serological screening to determine status for infections such as HIV, rubella, and hepatitis B
Blood type and Rh
Urine drug screen


Newborn Resuscitation
In addition to remembering the CABs (or circulation-airway-breathing), keep in mind some of the special
features of newborn resuscitation:
Warm and dry the infant and remove any wet linens immediately.
Infants have a large surface area relative to their body weight and can thus experience significant
hypothermia from evaporation.

Stimulate the infant to elicit a vigorous cry.
Helps clear the lungs and mobilize secretions.

Suction amniotic fluid from the infant's nose and mouth.
This helps clear the upper airway.

Initiate further resuscitation if required.
This may include using blow-by oxygen, positive pressure (bag-valve mask) ventilation with oxygen, chest
compressions, and even medications. The newborn resuscitation pyramid gives a graphic representation of
the frequency with which each of these interventions are required.

Appearance (skin color)
Pulse (heart rate)
Grimace (reflex irritability)
Activity (muscle tone)
Respiration


Either erythromycin, tetracycline or silver nitrate (E), is given to specifically prevent gonococcal conjunctivitis

Hearing loss in infants who have congenital CMV infection is often progressive (A).

Thomas already has hearing loss on the newborn hearing screen, but in many infected infants, the onset
of hearing loss may be after the newborn period.
Even if the newborn hearing screen is normal, an infant infected with CMV may develop hearing loss
and progress to severe-to-profound bilateral hearing loss during the first year of life.
Microcephaly and intracranial calcifications are associated with an increased risk of CNS sequelae of congenital
CMV infection, such as developmental delay (B).

Thomas must have ongoing developmental assessments and may ultimately demonstrate mental
retardation and/or cerebral palsy.
The nonneurological neonatal clinical abnormalities of CMV infection, hepatosplenomegaly and rash, can be
expected to resolve spontaneously within weeks (C).

Thomas is a candidate for antiviral treatment for CMV (D).

Studies have shown decreased progression of hearing impairment and diminished developmental
impairment in infants with congenital CMV infection and CNS involvement when they are treated with
either parenteral ganciclovir or oral valganciclovir. Due to possible hematologic and other toxicities, use
of these antivirals is not routine, but is currently recommended in this cohort of infants if they are able to
start therapy within the first month of life.

Breastfeeding

Indications

Recognized by the American Academy of Pediatrics as the optimal feeding for infants.
Exclusive breastfeeding is recommended for the first 6 months of life, and then breastfeeding plus
complementary foods until the infant is at least 12 months of age.
Breast milk plus fortifier is recommended for premature babies.
Mothers should nurse their babies whenever there are signs of hunger, which often is 8-12 times per day.

Absolute Contraindications
Rare.
May include maternal HIV infection; active, untreated tuberculosis; active maternal drug abuse; and infants
with galactosemia.


Benefits

Stimulates gastrointestinal growth and motility, which enhances the maturity of the gastrointestinal tract.
In both developed and developing nations, human milk compared to formula decreases the risk of acute
illnesses during the time that the infant is fed breast milk.
Breastfed babies have lower rates of diarrhea, acute and recurrent otitis media, and urinary tract infections.
There are reported associations between the duration of breastfeeding and a reduction in incidence of
obesity, cancer, adult coronary artery disease, certain allergic conditions, type 1 diabetes mellitus, and
inflammatory bowel disease.

A number of studies have shown small neurodevelopmental advantages, including cognitive and motor
development.

Potential maternal benefits include decreased risk of breast and ovarian cancer and osteoporosis.


Education/Assessment

Prior to hospital discharge, evaluate adequacy of latch-on, suckling and milk transfer, and progress of
lactogenesis.

Provide mothers with the education, resources, and follow-up to ensure breastfeeding success.

Within 24 to 48 hours after discharge, in-home lactation specialist or physician needs to assess adequate
urine and stool output as well as weight change.

- Congenital CMV = chorioretinitis, jaundice, progressive hearing loss + intracranial Ca2+


Routine Newborn Discharge Instructions
Red flags requiring immediate evaluation (including signs of significant jaundice)
Feeding instructions and signs of poor feeding
Safety issues (including placing the newborn on his back to sleep, proper infant auto restraint, and how to
access emergency help)



Case #2

Neonatal resp. distress
Risks:
Maternal diabetes (A) is a risk factor for respiratory distress syndrome (RDS), among other difficulties.
Prematurity (B) predisposes to RDS caused by lung immaturity and lack of surfactant; however, most
infants born at 36 weeks' gestational age do not have RDS.
Maternal group B strep infection (C) is a risk factor for neonatal sepsis (a cause of respiratory distress).
C-section delivery (F) predisposes to transient tachypnea of the newborn (TTN).
Premature rupture of membranes 18 hours (prolonged PROM, a risk factor for neonatal sepsis)
Meconium in the amniotic fluid (a risk factor for meconium aspiration syndrome)

Ddx
Diagnosis Comments
Respiratory distress
syndrome (RDS)
Caused by a deficiency of lung surfactant and delayed lung maturation

Can occur as late as 37 weeks' gestation

RDS causes tachypnea and is therefore an important consideration in this case
Most common cause of respiratory distress in premature infants

Remember that there may be surfactant deficiency and delayed lung maturation in
infants of diabetic mothers
Transient tachypnea
of the newborn (TTN)
Result of delayed clearance of fluid from the lungs following birth

Much more common in infants born to diabetic mothers and in infants born by c-
section

While generally considered a disorder of term infants, TTN does occur in premature
infants

This is a very likely diagnosis for Adam
Pneumothorax
Caused by a collection of gas in the pleural space with resultant collapse of lung
tissue.
Common risk factors are mechanical ventilation or underlying lung disease
(especially meconium aspiration or severe infant respiratory distress syndrome).
While relatively uncommon, always an important consideration in an infant with
respiratory distress

More likely in a premature infant with RDS
Hypoglycemia
May be seen in infants of diabetic mothers due to the chronic hyperinsulinemic state
that occurred during gestation.
Can be more pronounced in premature infants.
Tachypnea is a non-specific response to this metabolic derangement.
Congestive heart
failure (CHF)
In an infant, most often caused by a congenital heart defect
May present with early cardiac failure and tachypnea.

Increased risk of heart defects in IDM infants, and therefore an increased risk of CHF
Neonatal sepsis
Can present initially with tachypnea and progress to more severe illness rapidly
Often due to infection with Group B Streptococcus (GBS), usually transmitted from the
mother during labor (in this case, we do not know whether the mother was a GBS
carrier; therefore, this is an important diagnosis to consider, especially in a premature
infant)

Prolonged PROM (not present in this case) is associated with an increased incidence of
neonatal sepsis
Congenital
diaphragmatic hernia
Malformation resulting from a defect in the development of the diaphragm
Occurs in 1 out of every 2,200 to 5,000 live births

Most common type (accounting for > 95% of cases) is the Bochdalek hernia, which
is located posterolaterally.

This defect allows the passage of organs from the abdomen into the chest cavity and
severely impairs lung development.
Most defects occur on the left side.

Absent breath sounds or presence of bowel sounds on one side of the chest are
important diagnostic clues.
Severe coarctation of
the aorta
May cause respiratory distress if there is severe left ventricular outflow tract
obstruction.

AGA (appropriate for gest age) = 10-90%ile for birth wt
SGA (small for gest age) = < 3%ile or < 10%ile (depends on scale)
LGA = > 90%ile

The SGA or IUGR baby has unique potential problems, which may include:
Temperature instability (hypothermia)
Inadequate glycogen stores (hypoglycemia)
Polycythemia and hyperviscosity


First Hour
In the first hour of life, as transition occurs, the respiratory and heart rates are often elevated:

Heart rate is often 160-180 per minute, and the respiratory rate is often 60-80 per minute.

Second Hour
In an infant with a successful transition, by the age of 2 hours:
Heart rate is usually 120-160 per minute, and the respiratory rate is usually 40-60 per minute.

2
nd
hr value = nl for entire neonatal period (< 1mo)

Conditions to Consider in the Cyanotic Newborn

Respiratory
Common

TTN
RDS

Uncommon
Pneumothorax
Diaphragmatic hernia

Choanal atresia

Pulmonary hypoplasia
Cyanotic
congenital
heart defects
Common

Tetralogy of Fallot

Transposition of the great arteries (TGA): Defect in which
the aorta and pulmonary arteries are transposed, resulting in
respiratory distress and severe cyanosis as the ductus
arteriosus closes shortly after birth. One risk factor for TGA is
being born to a diabetic mother. TGA is often associated with other
congenital heart defects, such as a ventricular septal defect, so a murmur
may be heard on physical examination.

Uncommon

Truncus arteriosus

Tricuspid atresia
Total anomalous pulmonary venous return
Pulmonary atresia
CNS
Hypoxic-ischemic encephalopathy
Intraventricular hemorrhage
Sepsis/meningitis
Infectious
Septic shock
Meningitis
Other
Respiratory depression secondary to maternal medications
Hypothermia
Polycythemia/hyperviscosity syndrome