Pediatric Examination and Board Review (206 page)

(B) 48 hours

(C) 72 hours

(D) more than 72 hours

(E) no observation is needed if parents have available transportation and a working phone

ANSWERS

1.
(E)
A treponemal test, usually the FTA-ABS, remains reactive for life even after adequate therapy. Although any positive RPR or similar test must be confirmed to be syphilis by a test like the FTA-ABS. RPR and VDRL test are nontreponemal tests used to screen patients for syphilis. The nontreponemal tests have high sensitivity but relatively low specificity for the diagnosis of syphilis. They provide quantitative results that can be used to monitor response to therapy and define disease activity. Thus, a rise is the RPR or VDRL titer would suggest active syphilis. However, the RPR can be falsely negative in late congenital syphilis. A false-positive RPR can be associated with viral infections (eg, infectious mononucleosis, varicella, measles, and hepatitis) as well as lymphoma, tuberculosis, malaria, connective tissue disorders, and pregnancy itself.

2.
(B)
Neonatal RPR titers 4 times or more the mother’s titers are said to be indicative of congenital infection. Likewise, a fourfold or more decrease in a maternal RPR titer is indicative of successful treatment in the mother. Congenital syphilis can be divided into early and late stages. In the early stage, congenital syphilis symptoms may begin any time during the first 2 years of life, even if the neonate is asymptomatic at birth. Parenteral penicillin is the treatment of choice for congenital syphilis. The Jarisch-Herxheimer reaction (fever, chills, malaise, rash, hypotension, tachycardia after treatment of syphilis) is rare in the immediate newborn period.

3.
(D)
All are possible manifestations of congenital syphilis except PDA, which is commonly associated with congenital rubella syndrome. Myocarditis may be a manifestation of congenital syphilis.

4.
(A)
Gastroschisis (see
Figure 115-1
) in the neonate is associated with maternal cocaine use. Ebstein anomaly is associated with maternal use of lithium. LGA babies are commonly associated with diabetic and/or obese mothers. Neural tube defects are associated with the maternal use of anticonvulsants. One study has linked maternal use of metamizole, a nonsteroidal, anti-inflammatory drug banned in many parts of the world, to an increased risk of Wilms tumor in their children.

FIGURE 115-1.

5.
(A)
Neonatal abstinence syndrome (NAS) is classically associated with maternal opiate use during pregnancy but has been attributed to maternal use of other drugs, including ethanol, tobacco, and caffeine. Neonates affected by NAS tend to be very irritable with high-pitched crying, sweating, diarrhea, vomiting, poor feeding, and restlessness/hyperactivity. A standardized NAS scoring form is used to assess severity and to help determine a need for medical therapy. In the delivery room, if a mother is known to abuse opiates, naloxone is not indicated for the baby because abrupt drug withdrawal may provoke seizures. Supportive care such as a low-lit environment with minimal stimulation is important. The affected neonate will have an increased metabolism, so adequate intake with higher calorie formula or fortified breast milk is essential. Severe diarrhea may lead to skin irritation and breakdown in the diaper area, so frequent diaper changes and good topical barriers are key. If medical therapy is indicated for withdrawal symptoms, phenobarbital or an oral opiate may help.

6.
(E)
Infants born with fetal alcohol syndrome (FAS) and those with anticonvulsant embryopathy have similar, overlapping clinical features. FAS infants tend to be SGA and have microcephaly, whereas those with anticonvulsant embryopathy usually do not have either.

7.
(C)
Early-onset vitamin K–deficient hemorrhagic disease of the newborn is a well-documented complication of infants born to mothers who used anticonvulsants during pregnancy.

8.
(C)
Macrolides like erythromycin or lincosamides like clindamycin are indicated for intrapartum antibiotic prophylaxis against GBS if the mother has a history of anaphylaxis to penicillins. Whereas the penicillins are close to 100% effective in preventing early-onset GBS disease, there is up to 15% resistance among GBS strains with macrolides. Thus susceptibility testing in the prenatal period is essential when culturing for GBS if these alternative drugs are contemplated. If there is known resistance to the macrolides, vancomycin is the third-line prophylactic agent for IAP.

9.
(B)
Intrapartum prophylaxis is not intended to prophylaxis against late-onset disease. An increase in neonatal sepsis due to other causes than GBS has not been documented.

10.
(E)
Congenital GBS sepsis can be divided into early onset (in the first week of life) and late onset (day of life 8 to 3 months of age) infection. Early-onset infection tends to occur in the first day of life and can present with nonspecific signs such as poor feeding, temperature instability, nasal flaring, and lethargy. Late-onset infection, which may also present with nonspecific signs and symptoms, commonly presents with signs of meningitis that can, of course, be subtle in a young infant.

11.
(B)
A positive FTA-ABS test can occur secondary to passively acquired immune globulin (Ig)G antibody and may take 1 year or longer to become negative.

12.
(B)
Serologic tests such as RPR and VDRL may be falsely negative in very early congenital syphilis that had an infection onset within 4-6 weeks of term.

13.
(B)
The mother’s RPR, if she was adequately treated 2 years ago, should have become nonreactive by now. Her titer of 1:4 could represent new infection. There is no documented immunity to protect against reinfection.

14.
(C)
The baby should be treated for congenital syphilis. The mother’s titer of 1:4 at delivery might represent reinfection. Benzathine penicillin delivers inadequate levels of penicillin to reliably treat any possible CNS disease. There is no test available to exclude the possibility of CNS syphilis with certainty, although many mistakenly believe that a normal LP excludes neurosyphilis.

15.
(B)
If a mother is treated for syphilis less than 1 month before delivery with any antibiotic regimen, her baby should be evaluated and treated for congenital syphilis, irrespective of GBS intrapartum prophylaxis.

16.
(B)
Although intrapartum penicillin was not administered, the risk for GBS infection is still low. Observation after a minimal investigative evaluation is acceptable.

17.
(A)
Modern technology in use in clinical microbiology laboratories monitors blood culture bottles continuously for CO
₂
production. A blood culture specimen in which bacteria are growing may turn positive at any time. However, most cultures “turn positive” very quickly and yield positive results in 1-2 days.

18.
(A)
Despite intrapartum antimicrobial prophylaxis, which has greatly decreased the occurrence of early onset (<7 days) GBS disease, most cases are still recognized on the first day of life.

19.
(B)
Even though the mother was known to be a carrier, the risk of GBS disease is still relatively low in a term baby, and most cases are recognized on the first day of life. Along with the fact that the U.S. health system does not generally support prolonged observation of asymptomatic term babies, 48 hours of observation is believed by most experts to be sufficient.

S
UGGESTED
R
EADING

American Academy of Pediatrics. Syphilis. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds.
Red Book 2009 Report of the Committee on Infectious Diseases.
28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

Behrman RE, Kliegman RM, Jenson HB. Syphilis. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds.
Nelson Textbook of Pediatrics.
18th ed. Philadelphia, PA: WB Saunders; 2007.

Chakraborty R, Luck S. Managing congenital syphilis again? The more things change . . .
Curr Opin Infect Dis
. 2007;20(3):247-252.

Gotoff SP. Group B Streptococcal infections.
Pediatr Rev
. 2002;23(11):381-386.

Maisels MJ. Neonatal jaundice.
Pediatr Rev
. 2006;27(12):443-453.

Screening for syphilis infection in pregnancy: U.S. Preventive Services Task Force reaffirmation recommendation statement.
Ann Intern Med.
2009;150(10):705-709.

CASE 116: A NEONATE WITH HYPERPIGMENTED MACULAR SKIN FINDINGS

A full-term 2620-g infant is born to a 28-year-old G2P2 mother who had regular prenatal care. You were asked to attend the delivery because of meconium-stained amniotic fluid. The baby is born in good condition with Apgar scores of 9 and 9. No special interventions are required. As you examine the baby, you notice six discrete, round, 0.5-cm, hyperpigmented macular lesions on the abdomen, back, and left calf. The parents are not related to each other, and both deny any similar lesions in family members on either side.

SELECT THE ONE BEST ANSWER

1.
What is the most accurate statement about these lesions?

(A) “the baby is abnormal, I’m not sure”