Breathless Baby Flashcards
1
Q
What questions do you want to ask about poor feeding?
A
- Ask about volume of milk taken before and now
- Timescale of decline in feeding - important to get idea of duration of illness as feeding is often important first sign
- Why they stopped feeding e.g. child is breathless, goes pale and clammy
- Sleepiness = very worrying sign - need to explore this more especially if affecting feeding (sleeping longer at night, not crying for usual feed)
- Does mum have any other ideas about precipitating factor - parents often have more time than you do to think around the problem - may not know medical reasons but can give other clues e.g. we have all had a cold
2
Q
How is the milk requirement calculated?
A
- Until a baby meets their birth weight, continue using their BW for calculation, not current weight
- Up to a month of age the minimum milk requirement to provide enough calories to grow is 150mls/kg/day
- After 1 month this can be down to 100mls/kg minimum so long as they are gaining weight
3
Q
What is asked in the antenatal history?
A
- Scans and screening - maybe congenital disease
- Maternal health - looking for congenital infections, vascular episodes following antenatal bleeds, trauma, medication, teratogenic agents including high sugar
- Delivery - looking for increased risk of infection with prolonged rupture of membranes
- The gestation, mode of delivery and weight
- Post delivery - any time on the neonatal unit, looking at respiratory causes, hypoglycaemic screening, concerns around sepsis
- Routine immunisation schedule starts at 2 months
4
Q
What are the differentials and presentations of a breathless baby?
A
- Vascular: symptomatic on exercise I.e. feeding, clammy, sleepy; no hx of antenatal/perinatal trauma, normal anomaly scan
- Infective, inflammation, immune: sleepy, snuffly, poor feeding, not yet immunised; new borns at increased risk as immature immune system
- Traumatic: includes child protection, non accidental injuries
- Autoimmune: FH of anything
- Metabolic (includes inborn errors of metabolism): consanguinity, sleepy, poor feeding
- Iatrogenic/idiopathic: teratogenic medications
- Congenital/genetic: antenatal screening and scans
- Developmental/degenerative: sleep and poor feeding, encouraging factors include normal development up until now
- Endocrine/environment: FH e.g. diabetes, thyroid
- Functional: post-natal depression
5
Q
What do you look for on inspection of a child?
A
- General dysmorphism
- Neurology I.e. alert, happy, interacting, responding to voice, pain, unresponsive - also look at muscle tone and abnormal movements
- Colour: check if jaundiced, mottled/pale or cyanosed (sats need to be <85% for cyanosis to show)
- Extra noises: grunting, stridor, wheeze, crying, coughing
- Signs of pain: abdominal posturing, grimacing or relaxed
- Obvious marks/rashes: marks/bruises around face/ears/lips/orbital swelling
- Any secretions: any crusting in eyes? Any nasal secretions
- Signs of increased work of breathing: nasal flaring, head bobbing, subcostal recession, tracheal tug etc
- RR
- Measure length, head circumference, BP and check body for bruises
6
Q
What are possible causes of abnormal respiratory breathing in neonates?
A
- Primary respiratory disease e.g. bronchiolitis
- Congenital abnormalities, like diaphragmatic hernia
- Cardiac disease e.g. heart failure
- Shock due to hypovolaemia (compensating for poor perfusion, hypoxia) e.g. sepsis
- Acute blood loss secondary to injury I.e. subdural
- Metabolic issues with compensatory breathing like acidosis/metabolic alkalosis
- Endocrine e.g. DKA - Kussmaul breathing (laboured, deeper breathing rate)
- Always consider sepsis
7
Q
What are possible causes for tachycardia?
A
- Upset/fear (stranger fear)
- Pyrexia
- Pain
- Cardiac arrhythmia I.e. SVT = HR >220
- Increased work e.g. accessory muscles for breathing or exercise
- Cardiac/circulatory failure e.g. increased CRT, enlarged liver, cool peripheries, clammy on feeding
- Shock including hypovolaemia secondary to accidental or non-accidental injury
- Shock hypovolaemia secondary to third space loss such as sepsis - cool extremities
- Endocrine e.g. hypothyroid
8
Q
What congenital heart defects cause a large heart?
A
- Large left to right shunts
- VSD (cardiomegaly with pulmonary plethora), PDA
- TGA
- Tricuspid atresia
- Single ventricle
- Truncus Arteriosus
- Ebstein’s anomaly
9
Q
What congenital heart defects cause a small heart?
A
- Fallot’s tetralogy (boot shaped) - dark lung fields due to pulmonary oligemia
- TAPVD - infradiaphragmatic
10
Q
What congenital heart defects cause a normal sized heart?
A
- TGA
- Pulmonary atresia
11
Q
What does plethoric mean?
A
Too much blood going into lungs - left to right shunts e.g. VSD, PDA, cardiac failure
12
Q
What does oligarchic mean?
A
Very dark XR due to less blood going into lungs - Fallot’s tetralogy, pulmonary atresia/stenosis
13
Q
Describe VSD
A
- Pansystolic/holosystolic murmur - lower left sternal border
- Blood shifted from left to right ventricle down pressure gradient
- Hole can form in membranous septum (higher up in ventricle wall) or in muscular septum (lower down). Can hear membranous septum more clearly on auscultation.
- If hole is small then typically asymptomatic so can be left alone but if hole is large can be fixed by surgery
- Not unusual to have normal fetal anomaly scans and then have VSD postnatally (maternal obesity makes scanning difficult)
- Murmur is often absent at the baby check done at a few hours of age due to the changes in pressure within the heart as it changes from foetal to adult circulation.
14
Q
What heart conditions can present with no murmurs?
A
- Transposition of great arteries (TGA)
- Total anomalous pulmonary venous drainage (TAPVD)
15
Q
What causes systolic murmurs?
A
- Fallot’s tetralogy
- VSD
- Pulmonary/aortic stenosis
