Neonatology Practice Questions

Q: What is the daily fluid requirement for a 3-day-old baby with a birth weight of 1500 grams?

80-90 ml/kg/day. ***80-90 ml/kg/day***- This range represents the typical fluid requirement for a very low birth weight (**VLBW**) infant on the second or third day of life (DOL 2-3).- It allows for a safe transition from the restricted fluids (60-80 ml/kg/day) of DOL 1 towards higher maintenance needs, minimizing the risk of conditions like **patent ductus arteriosus (PDA)**.*100-110 ml/kg/day*- This rate is usually required later in the first week (around **DOL 4 to DOL 7**) as the infant's renal function matures and catabolism increases.- Providing this high volume prematurely to a 3-day-old **VLBW** infant increases the risk of **fluid overload** and associated neonatal morbidities.*120-130 ml/kg/day*- This represents a standard high maintenance fluid rate, typically achieved by **DOL 7** or later, especially for infants utilizing **phototherapy**.- It is significantly above the required baseline for a **3-day-old** baby and would lead to potential hyponatremia and **pulmonary edema**.*130-150 ml/kg/day*- This is the usual **full maintenance** or "maximal" fluid requirement often seen after the first week of life (DOL 7+) or in situations requiring high replacement.- Administration of this rate on DOL 3 is strongly discouraged due to the extreme risk of **cardiovascular and pulmonary complications**.

Q: A neonate was brought with a history of frothiness from the mouth and respiratory distress. An X-ray of the neonate is given below. What is the diagnosis?

Esophageal atresia with tracheo-esophageal fistula. ***Esophageal atresia with tracheo-esophageal fistula*** - The clinical presentation of a neonate with excessive **frothiness from the mouth**, choking, and **respiratory distress** is highly suggestive of this diagnosis. - The X-ray confirms the diagnosis by showing a **coiled orogastric tube** (indicated by the arrow) in the blind-ending upper esophageal pouch. The presence of **gas in the stomach** indicates a communication between the trachea and the distal esophagus (a distal fistula). *Transient tachypnea of newborn* - This is a benign condition caused by delayed clearance of fetal lung fluid, presenting with rapid breathing shortly after birth, usually in term infants delivered by C-section. - The chest X-ray typically shows **perihilar streaking**, **fluid in the fissures**, and mild hyperinflation, not a coiled feeding tube. *Congenital diaphragmatic hernia* - This condition involves the herniation of abdominal contents into the chest, causing severe respiratory distress and a **scaphoid abdomen**. - The chest X-ray would show **bowel loops within the thoracic cavity** and displacement of the mediastinum, which are not seen in this image. *Respiratory distress syndrome* - Primarily seen in premature infants, this is caused by a deficiency of **pulmonary surfactant**. - The characteristic X-ray findings include low lung volumes, a diffuse **ground-glass appearance**, and **air bronchograms**.

Q: How much oxygen is given to a term infant with respiratory distress during resuscitation?

21%. ***Correct: 21% (Room Air)*** - **Current NRP and WHO guidelines** recommend starting resuscitation of **term infants with 21% oxygen (room air)** - Evidence shows room air is **equally effective** as 100% oxygen for initial resuscitation - Reduces **oxidative stress and potential harm** from hyperoxia - Oxygen can be **titrated up** if preductal SpO2 targets are not achieved within expected timeframes - This applies specifically to **term infants (≥37 weeks gestation)** *Incorrect: 70%* - Not a standard concentration used in neonatal resuscitation - Would expose infant to unnecessarily high oxygen levels without clear benefit *Incorrect: 100%* - **Outdated practice** - previously used but no longer recommended for term infants - Associated with increased **oxidative stress** and potential harm - May still be considered for **preterm infants <35 weeks** (start with 21-30% and titrate) *Incorrect: 50%* - Not the recommended starting concentration for term infants - May be used as an **intermediate step** when titrating oxygen if initial room air is insufficient **Key Point:** For term infants, always start with room air (21%) during resuscitation and titrate based on SpO2 targets.

Q: A neonate delivered at 36-week gestation develops respiratory distress soon after birth. CXR is as shown. Likely diagnosis?

Respiratory Distress Syndrome. ***Respiratory Distress Syndrome*** - The chest X-ray shows classic features of RDS, including a diffuse **reticulogranular pattern** (ground-glass appearance) and prominent **air bronchograms**, indicative of widespread alveolar atelectasis. - This condition is primarily caused by **surfactant deficiency** in preterm infants (like this 36-week neonate), leading to increased surface tension, alveolar collapse, and respiratory distress shortly after birth. ***Transient Tachypnea of Newborn*** - This is caused by delayed clearance of **fetal lung fluid** and is more common in term infants delivered by Caesarean section. - The chest X-ray typically shows **perihilar streaking**, fluid in the interlobar fissures, and hyperinflation, which are not the primary findings in the provided image. ***Neonatal Pneumonia*** - While it can present with respiratory distress, neonatal pneumonia typically shows **asymmetrical patchy infiltrates**, consolidation, or pleural effusions on chest X-ray. - The diffuse, symmetrical ground-glass appearance seen here is less characteristic of an infectious process like pneumonia, which is often more localized. ***Meconium Aspiration Syndrome*** - This condition occurs in term or post-term infants following aspiration of **meconium-stained amniotic fluid**, which is not mentioned in the history. - The characteristic X-ray findings are coarse, patchy opacities, **hyperinflation**, and potential air-leak syndromes (e.g., pneumothorax), which differ from the image.

Q: Positive pressure ventilation (PPV) in neonatal resuscitation is indicated in all of the following except:

Nonvigorous child born through meconium stained liquor. ***Nonvigorous child born through meconium stained liquor*** - The latest NRP guidelines advise against routine **intubation for tracheal suctioning** for *non-vigorous* infants born through meconium-stained amniotic fluid. - Instead, initial steps should focus on providing **positive pressure ventilation (PPV)** if the infant is apneic or gasping. *Apnea* - **Apnea** (absence of breathing) is a direct indication for initiating **positive pressure ventilation** in neonatal resuscitation. - An infant who is not breathing effectively requires immediate respiratory support. *Heart rate less than 100 BPM* - A **heart rate below 100 BPM** in a newborn baby is a critical indicator for initiating **positive pressure ventilation**. - This signifies inadequate oxygenation and perfusion, necessitating immediate intervention to improve oxygen delivery. *Persistent central cyanosis in spite of 100% free flow oxygen* - **Persistent central cyanosis** despite provision of 100% free-flow oxygen indicates a significant respiratory or cardiac issue requiring further intervention, often including **positive pressure ventilation**. - Free-flow oxygen alone is insufficient to correct profound hypoxemia in such cases.

Q: A neonate is being resuscitated as shown in the image. What is the ratio of chest compressions:rescue breaths for this patient?

3:1. ***3:1*** - The image depicts a **neonate or infant** undergoing CPR, indicated by the two-thumb encircling technique for chest compressions. - For **neonatal resuscitation** (newborns in the delivery room and early neonatal period), the recommended compression-to-ventilation ratio is **3 compressions to 1 breath** as per NRP guidelines. - This ratio ensures adequate ventilation for presumed asphyxial cardiac arrest while maintaining coordinated compressions. *5:1* - This ratio is **NOT recommended** in current resuscitation guidelines (AHA/ILCOR/NRP). - This may cause confusion with older or obsolete protocols, but it is not part of modern CPR algorithms. *15:2* - The 15:2 ratio is recommended for **two-rescuer CPR in infants and children** (beyond the neonatal period). - This ratio aims to maximize ventilations while maintaining effective chest compressions in a team setting. - This is NOT used for neonatal resuscitation in the delivery room. *30:2* - The 30:2 ratio is the standard for **adult CPR** and **single-rescuer CPR in infants and children** (beyond neonatal period). - It prioritizes compressions over breaths and is used when only one rescuer is available. - This is NOT appropriate for neonatal resuscitation where the 3:1 ratio is preferred.

Q: What ventilation modality is shown below?

Nasal CPAP. ***Nasal CPAP*** - The image shows a device applied to the nose of an infant, providing a continuous flow of air which is characteristic of **Nasal Continuous Positive Airway Pressure (nCPAP)**. - This modality helps maintain lung volume, improve oxygenation, and reduce the work of breathing in neonates with respiratory distress. *High frequency jet ventilation* - This modality involves delivering small tidal volumes at very **high frequencies** (hundreds of breaths per minute) through a specialized ventilator and endotracheal tube. - The image does not depict an **endotracheal tube** or the rapid, small tidal volume delivery characteristic of jet ventilation. *Inverse ratio ventilation* - This is a mode of **mechanical ventilation** where the inspiratory time is longer than the expiratory time (I:E ratio > 1:1), typically used in intubated patients. - The image shows a non-invasive nasal device, not an **intubated patient** on a mechanical ventilator. *Intermittent positive pressure ventilation* - This refers to delivering breaths with positive pressure, either invasively (via endotracheal tube) or non-invasively (via mask), to assist or control breathing. - While CPAP provides positive pressure, "intermittent positive pressure ventilation" implies cyclical breaths, which is not the primary defining feature shown, and CPAP (continuous pressure) is a more specific and accurate description for the depicted setup.

Q: A child presents in the first week of life with recurrent vomiting, failure to thrive. On examination enlarged liver and spleen are palpated. Blood work shows hyperlipidemia and deranged LFT. CT abdomen was performed. What is the clinical diagnosis?

Wolman disease. ***Wolman disease*** - The constellation of **recurrent vomiting**, **failure to thrive**, **hepatosplenomegaly**, **hyperlipidemia**, **deranged LFTs** in an infant, and the presence of **adrenal calcifications** on CT abdomen (as suggested by the image showing bright areas above the kidneys) are highly characteristic of Wolman disease. - Wolman disease is a **lysosomal storage disorder** caused by a deficiency in **lysosomal acid lipase**, leading to the accumulation of cholesteryl esters and triglycerides in various tissues, particularly the liver, spleen, and adrenal glands. *Von Gierke disease* - This is a **glycogen storage disease** (Type I), characterized by **hypoglycemia**, lactic acidosis, hyperlipidemia, and hepatomegaly, but typically **without adrenal calcifications** or splenomegaly as prominent features in the first week of life. - While it causes hepatomegaly and hyperlipidemia, the profound adrenal calcification seen on CT rules it out as the primary diagnosis given the presented image. *Tay-Sachs disease* - This is a **lysosomal storage disorder** affecting hexosaminidase A, leading to GM2 ganglioside accumulation, primarily in neurons. - Clinical presentation involves **neurological deterioration**, **cherry-red spot on the retina**, and seizures, but typically **no hepatosplenomegaly, adrenal calcifications, or significant liver dysfunction**. *Biotinidase deficiency* - This is a metabolic disorder affecting biotin metabolism, presenting with **neurological symptoms** (seizures, hypotonia), skin rash, and alopecia. - It does **not typically involve hepatosplenomegaly, hyperlipidemia, or adrenal calcifications**.

Q: A 2-hour-old neonate born by normal vaginal delivery has a scalp swelling, with normal cry and activity. What is the probable cause?

Serosanguinous subcutaneous fluid. ***Serosanguinous subcutaneous fluid*** - This description is consistent with **caput succedaneum**, a common finding in neonates after vaginal delivery. It is a **diffuse, edematous swelling of the scalp** that crosses suture lines, caused by pressure during birth. - The swelling arises from **serosanguinous fluid** accumulating in the **subcutaneous tissues** (between the skin and galea aponeurotica) and typically resolves within a few days. *Focal subaponeurotic blood collection* - This describes a **subgaleal hemorrhage**, which involves blood collection *between the scalp aponeurosis and the periosteum*. - Subgaleal hemorrhages can be very extensive and life-threatening, often presenting with signs of **hypovolemic shock** as it can accumulate a large amount of blood, which is inconsistent with the "normal cry and activity" of the neonate. *Chignon* - A chignon is a **localized scalp edema** or swelling that forms as a result of a **vacuum extractor** application during delivery. - While it is a scalp swelling, the question states "normal vaginal delivery" and does not mention vacuum extraction, making it less likely. *Depressed skull fracture* - A **depressed skull fracture** involves an indentation of the skull bone, which would be a **hard, bony defect** rather than a soft, fluid-filled swelling. - While it can occur during birth, it is usually a more severe injury and might present with neurological symptoms or a palpable bony depression, neither of which are described.

Question 1

What is the daily fluid requirement for a 3-day-old baby with a birth weight of 1500 grams?

Accepted Answer

80-90 ml/kg/day

Answer

100-110 ml/kg/day

Answer

130-150 ml/kg/day

Answer

120-130 ml/kg/day

Question 2

A neonate was brought with a history of frothiness from the mouth and respiratory distress. An X-ray of the neonate is given below. What is the diagnosis?

Accepted Answer

Esophageal atresia with tracheo-esophageal fistula

Answer

Transient tachypnea of newborn

Answer

Respiratory distress syndrome

Answer

Congenital diaphragmatic hernia

Question 3

How much oxygen is given to a term infant with respiratory distress during resuscitation?

Accepted Answer

21%

Answer

70%

Answer

100%

Answer

50%

Question 4

A neonate delivered at 36-week gestation develops respiratory distress soon after birth. CXR is as shown. Likely diagnosis?

Accepted Answer

Respiratory Distress Syndrome

Answer

Meconium Aspiration Syndrome

Answer

Transient Tachypnea of Newborn

Answer

Neonatal Pneumonia

Question 5

Which of the following best explains the mechanism of breast milk jaundice?

Accepted Answer

Enhanced enterohepatic circulation due to beta-glucuronidase in breast milk deconjugating bilirubin

Answer

Increased RBC breakdown producing more unconjugated bilirubin

Answer

Reduced intestinal absorption of bilirubin

Answer

Hepatocellular injury by breast milk

Question 6

Positive pressure ventilation (PPV) in neonatal resuscitation is indicated in all of the following except:

Accepted Answer

Nonvigorous child born through meconium stained liquor

Answer

Apnea

Answer

Heart rate less than 100 BPM

Answer

Persistent central cyanosis in spite of 100% free flow oxygen

Question 7

A neonate is being resuscitated as shown in the image. What is the ratio of chest compressions:rescue breaths for this patient?

Accepted Answer

3:1

Answer

5:1

Answer

15:2

Answer

30:2

Question 8

What ventilation modality is shown below?

Accepted Answer

Nasal CPAP

Answer

High frequency jet ventilation

Answer

Inverse ratio ventilation

Answer

Intermittent positive pressure ventilation

Question 9

A child presents in the first week of life with recurrent vomiting, failure to thrive. On examination enlarged liver and spleen are palpated. Blood work shows hyperlipidemia and deranged LFT. CT abdomen was performed. What is the clinical diagnosis?

Accepted Answer

Wolman disease

Answer

Von Gierke disease

Answer

Tay-Sachs disease

Answer

Biotinidase deficiency

Question 10

A 2-hour-old neonate born by normal vaginal delivery has a scalp swelling, with normal cry and activity. What is the probable cause?

Accepted Answer

Serosanguinous subcutaneous fluid

Answer

Focal subaponeurotic blood collection

Answer

Chignon

Answer

Depressed skull fracture

Neonatology — MCQs

Neonatology — MCQs

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