Child health 3 Flashcards
Bacteraemia vs septicaemia
> bacteraemia = presence of bacteria in the BS
septicaemia = presence of pathogens in the BS -> sepsis
Diagnosing infections
> urine
blood tests & culture
CXR
lumbar puncture for CSF
resp secretions
swabs
Croup
> viral
hoarse voice
barking cough
resp distress
Epiglottis
> Bacterial
child looks septic, drooling, soft stridor
avoid examining
call for senior help
chemoprophylaxis
> refers to the administration of a medication for the purpose
of preventing disease or infection
When should vaccines be avoided
during febrile illness
absolute CI to vaccines
> Absolute CI: severe local or generalised reaction previously
Not given when on systemic steroids or immunosupression
Gap between ig and live vaccine administration
12 week gap between human immunoglobulin and live vaccine administration
vaccines: egg allergy
influenza, yellow fever, hepatitis A
What could be causing a pyrexia of unknown origin
> Infectious diseases – bacterial, viral, fungal, parasitic
Connective tissue disorders
Malignancy
Miscellaneous
• Drug fever
• Inflammatory bowel disease
• Sarcoidosis
Kawasaki disease
> fever lasting 5+ days without any other cause
at least 4 out of 5:
• Bilateral non-purulent conjunctivitis
• Polymorphous rash
• Cervical lymphadenopathy
• Peripheral peeling / oedema / erythema
• Oral mucous membrane changes
Causes of stridor in children
> Croup
acute epiglottis
laryngomalacia
inhaled foreign body
Features of inhaled foreign body
> Features are of sudden onset
coughing
choking
vomiting
stridor
Laryngomalacia
> Congenital abnormality of the larynx.
Infants typical present at 4 weeks of age with:
stridor
What is croup
> upper resp TI seen in infants and toddlers
stridor from laryngeal oedema and secretions
caused by parainfluenza viruses
more common in autumn
CF of croup
> cough - barking, worse at night
stridor (do not examine throat at the risk of prec airway obstruction)
fever
coryzal symptoms
inc work of breathing e.g. retraction
Grading severity of croup
> Image
Ix for croup
> Most diagnosed clinically
if a CXR is done:
PA view will show subglottic narrowing - steeple sign
lateral view will show swelling of the epiglottis - thumb sign
Mx of croup
> single dose of dexamethasone to all kids regardless of severity
predinsolone is the alt
Emergency Tx of croup
> high-flow oxygen
nebulised adrenaline
Epiglottitis
> caused by haemophilus influenza type B -> swelling can completely occlude airways -> life threatening
children vaccinated against haemophilus (higher risk in unvaccinated kids)
Presentation of epiglottitis in exams
> unvaccinated child presenting with a fever, sore throat, difficulty swallowing that is sitting forward and drooling and suspect epiglottitis.
Presentation Suggesting Possible Epiglottitis
> Patient presenting with a sore throat and stridor
Drooling
Tripod position, sat forward with a hand on each knee
High fever
Difficulty or painful swallowing
Muffled voice
Scared and quiet child
Septic and unwell appearance
investigations for epiglottitis
> if ppt acutely unwell then do not perform Ix
XR of neck shows thumb sign - soft tissue shadow that looks like a thumb pressed into the trachea.
Mx of eoglottitis
> do not distress the child
prepare to intubate
once airway is secure:
IV antibiotics (e.g. ceftriaxone)
Steroids (i.e. dexamethasone)
Common complication of epiglottitis
A common complication to be aware of is the development of an epiglottic abscess, which is a collection of pus around the epiglottis. This also threatens the airway, making it a life threatening emergency. Treatment is similar to epiglottitis.
Mx of mild croup at home
> Symptoms usually resolve within 48 hours, although some episodes may last for up to one week.
Parents/carers should be advised to give paracetamol or ibuprofen to control fever and pain and to seek urgent medical advice if there is any deterioration.
Hospital admission may be required in some cases, for example if there is chronic lung disease, congenital heart disease, immunodeficiency, respiratory rate of over 60 breaths/minute, high fever, or inadequate fluid intake.
croup - what is an indicatio for admission
Croup: audible stridor at rest is an indication for admission
Mild croup
> Occasional barking cough with no stridor at rest
No or mild recessions
Well looking child
Moderate croup
> Frequent barking cough and stridor at rest
Recessions at rest
No distress
Severe croup
> Prominent inspiratory stridor at rest
Marked recessions
Distress, agitation or lethargy
Tachycardia
most common cause of stridor in infants
laryngomalacia - made worse by eating
Bronciolotis
> acute bronchiolar inflammation
Caused by RSV
LTRI -> wheeze
Peaks in winter
what can cause bronchiolitis to be more severe
> premature
CF
congenital HD
features of bronchiolitis
> coryzal symptoms (including mild fever) precede:
dry cough
increasing breathlessness
wheezing, fine inspiratory crackles (not always present)
Immediate referral for bronchiolitis
> apnoea (observed or reported)
child looks seriously unwell to a healthcare professional
severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute
central cyanosis
persistent oxygen saturation of less than 92% when breathing air.
Ix for bronchiolitis
immunofluorescence of nasopharyngeal secretions may show RSV
Mx of bronchiolitis
> humidified O2 if sats under 92%
nasogasrric feeding if can’t feed enough by mouth
suction if excessive upper airway secretions
peak incidence of bronchiolitis
> aged 3-6 months
what necessitates referral to hospital in bronchiolitis
In bronchiolitis, the presence of grunting necessitates immediate referral to hospital - grunting shows severe resp distress
red flags under 5
> Red flags in febrile under 5s; RUSH G! Recessions (moderate or severe) - indicating increased work of breathing
Unarousable - indicating reduced consciousness
Skin colour changes (blue/mottled) - indicating severe cyanosis
Hydration - reduced skin turgor - indicating severe dehydration
Grunting - increased work of breathing
perthes disease is more common in
boys. Primary school kids
what is the diagnosic test for hirschsprungs disease
rectal biopsy - definitive
GORD in babies presentation
Infant < 8 weeks, presents with milky vomits after feeds, often after being laid flat, excessive crying → ? GORD
duodenal atresia presentation
> ould typically present earlier in life, possibly a few hours after birth. It would present with projectile and bilious vomiting
GE pres in an infant
Gastroenteritis is commonly caused by a viral infection, typically resulting in a fever and tachycardia. This could be associated with stool changes,
cardiac deficit assoc w fragile X
MVP
What is associated w kartagners syndrome
bronchiectasis
Perthes disease classical presentation
> 4-8 year old boy
irritable hip, limp (progressive), and reduced range of motion, despite no history of trauma or systemic symptoms
X ray can demonstrate epiphyseal sclerosis
usually unilateral
ToF features
> PROVE
pulmonary stenosis
RVH
Overriding aorta
VSD
Ejection systolic murmur
What inc risk of autism
> Trinucleotide repeat disorder of X chromosome
fragile X -> autism
what determines degree of cyanosis and severity in TOF
Right ventricular outflow obst
NSAIDs (ibuprofen) use in chicken pox
NSAIDs can increase the risk of necrotising fasciitis in patients with chicken pox
Mx of acute limp for kids
Urgent assessment should be arranged for a child < 3 years presenting with an acute limp - NICE guidance states transient synovitis is rare in this age group and septic arthritis more common - an urgent specialist assessment is therefore indicated for a child < 3 years with an acute limp.
Transient synovitis pres
> acute
after viral infection normally
more common in boys
Septic arthititis/ osteomyelitis
unwell child, high fever
Juvenile idiopathic arthiritis - limp
may be painless
DDH - diagnosis
> usually detected in neonates
6x more common in girls
Perthes vs SUFE
> Perthes - 4-8 (primary school kids)
avascular necrosis
SUFE - 10 -15 (secondary school), associated w obesity,
displacement of femoral head posteriorly
first signs of puberty
> girls: breast development
boys: testicular volume increases
ToF pres
: Cyanosis or collapse in first month of life, hypercyanotic spells. Ejection systolic murmur at left sternal edge
TGA vs TOF
> Cyanotic congenital heart disease presenting within the first days of life is TGA.
Cyanotic congenital heart disease presenting at 1-2 months of age is TOF
Red flag pointing at hirschsprungs
delayed passage of meconium
Infant with bilious vomiting & obstruction → ?
intestinal malrotation
chickenpox CF
prodrome of raised temperature before the rash begins on the torso and face
What can be given for chickenpox
topical calamine lotion
first lines for GORD
Breastfed infants: Prescribe a 1-2 week trial of an alginate e.g. Gaviscon)
Bottle fed baby: Prescribe a 1-2 week trial of feed thickener i
prophylaxis for aspleic/ hypospleic ppts
> 5 yr pneumococcal booster
labetolol use in mother increases risk of
hypoglycaemia, measure BG levels of baby
Most common presentation of neonatal sepsis
Grunting and other signs of respiratory distress are the most common presentation of neonatal sepsis
triad of fat embolism
> Triad of symptoms:
Respiratory
Neurological
Petechial rash (tends to occur after the first 2 symptoms)
Organisms causing post splenectomy sepsis:
> Streptococcus pneumoniae
Haemophilus influenzae
Meningococci
most common cause of neonatal sepsis
group B strep (strep agalactiae)
hypothermia - rapid rewarming can lead to
rapid rewarming can lead to peripheral vasodilation and shock
billous vomiting on first day is likely due to
atresia
referral for acute stridor
> moderate croup: paeds
foreign body aspiration: ENT
epiglottitis: A&E
Anaphylaxis (IM adrenaline -> ED)
viral URTI symptoms
> nasal discharge, nasal obstruction, sore throat, headache, cough, tiredness and general malaise.
signs of URTI
> Erythema or injection of the back of the throat
Nasal discharge
Tender cervical lymphadenopathy
Mild fever
chickenpox CF
> Fever initially
Itchy, rash starting on head/trunk before spreading. Initially macular then papular then vesicular
Systemic upset is usually mild
Measles CF
> Prodrome: irritable, conjunctivitis, fever
Rash: starts behind ears then to whole body, discrete maculopapular rash becoming blotchy & confluent
Spots seen in measles
koplik spots - white spots on buccal mucosa
mumps CF
> Fever, malaise, muscular pain
Parotitis (‘earache’, ‘pain on eating’): unilateral initially then becomes bilateral
rubella CF
> Rash: pink maculopapular, initially on face before spreading to whole body, usually fades by the 3-5 day
Lymphadenopathy: suboccipital and postauricular
Erythema infectiosum
> slapped cheek syndrome
caused by parovirus B19
Lethargy, fever, headache
rash in erythema infectosum
‘Slapped-cheek’ rash spreading to proximal arms and extensor surfaces
scarlet fever CF
> Reaction to erythrogenic toxins produced by Group A haemolytic streptococci
Fever, malaise, tonsillitis
‘Strawberry’ tongue
Rash in scarlet fever
> fine punctate erythema sparing the area around the mouth (circumoral pallor)
hand, foot and mouth disease is caused by
Caused by the coxsackie A16 virus
H F and M features
> Mild systemic upset: sore throat, fever
Vesicles in the mouth and on the palms and soles of the feet
infectivity of chicken pox
> 4 days before rash
infectious until all lesions crusted over (isolate from school)
newborns and IC patients and chicken pox
> IC and newborns w peripartum exposure should get varicella zoster immunoglobulin
consider IV aciclovir if CP develops
post exposure prophylaxis for CP
> sign exposure
risk of severe infection: IS, pregnancy, neonates
no ab to VZV
. Give varicella zoster immunoglobulin
Rf for shingles
> age
HIV
immunosuppression - steroids, chemo
features of shingles
> most commonly affects T1-L2 dermatomes
burning pain over affected deratome, may be severe enough to interfere w sleep
rash - macular but then becomes vesicular
rash does nort cross the midline - stays within dermatome
Mx of shingles
> paracteamol/ NSAIDs first line for pain relief
Amitryptine can be used second
oral steroids if severe pain as 3)
Antivirals in shingles
> if moderate/ severe w RD
aciclovir or famciclovir
reduced incidence of post herpertic neuralgia
complications of shingles
> post herpetic neuralgia - most common
herpes zoster ophthalmicus
herpes zoster oticus (Ramsay Hunt syndrome): may result in ear lesions and facial paralysis
NSAIDs can be used in
shingles but not CP
features of kawasaki disease
> high fever, lasts more than 5 days - resistant to AP
conjunctivitis
bright red cracked lips
strawberry tongue
cervical lymphadenopathy
red palms of the hands and the soles of the feet which later peel
complication of kawasaki
coronary artery aneurysm - screened for using echo
Mx of kawasaki
> high dose aspirin
IV immunoglobulin
Measles pathogen
> RNA virus
aerosol transmission
incubation period 10-14 days
Ix of measles
> IgM antibodies can be detected within a few days of rash onset
Mx of measles
> admission may be considered in immunosuppressed or pregnant patients
notifiable disease → inform public health
Comps of measles
> otitis media: most common
pneumonia: most common cause of death
encephalitis - usually 1-2 weeks after onset
unvaccinated child who has come into contact w measles
give MMR vaccine within 72 hrs
when does mumps tend to occur
> RNA virus
winter and spring
Spread of measles?
> by droplets
respiratory tract epithelial cells → parotid glands → other tissues
infective 7 days before and 9 days after parotid swelling starts
Mx of measles
> rest
paracetamol for high fever/discomfort
notifiable disease
complications of measles
> orchitis (mainly post-pubertal males)
hearing loss - usually unilateral and transient
comps of rubella
> arthiritis
myocarditis
thrombocytopenia
incubation period for rubella
> incubation period is 14-21 days and individuals are infectious from 7 days before symptoms appear to 4 days after the onset of the rash.
rubella in pregnancy: congenital rubella syndrome
> sensorineural deafness
congenital cataracts
congenital HD - e.g. patent DA
Cerebral palsy
diagnosis of rubella
> IgM ab raised
check serology for parovirus b19
Mx of rubella
> suspected cases of rubella in pregnancy should be discussed with the local Health Protection Unit
non immune mothers should be offered MMR in post natal period
MMR should not be given to women known to be pregnant/ attempting to be (avoid pregnancy 28 days after MMR)
Eryrthema infecriosum - school exclusion
not required - no longer infectious by the time rash occurs
scarlet fever pathogen
Group A haemolytic streptococci (usually Streptococcus pyogenes
Rash of scarlet fever
> pinhead rash - usually on torso and spares palms and soles
children often have a flushed appearance with circumoral pallor. The rash is often more obvious in the flexures
rough sandpaper texture
desquamination occurs later in the course of the illness, particularly around the fingers and toes
Mx of scarlet fever
> oral penicillin V for 10 days
patients who have a penicillin allergy should be given azithromycin
children can return to school 24 hours after commencing antibiotics
scarlet fever is a notifiable disease
comps of scarlet fever
> otitis media: most common
rheumatic fever
acute glomerulonephritis
Mx of HFM
> symptomatic Tx
school exclusion not required
pneumonia CF
> Cough (typically wet and productive)
High fever (> 38.5ºC)
Tachypnoea
Tachycardia
Increased work of breathing
Lethargy
Delirium (acute confusion associated with infection)
Signs of pneumonoa
> can indicate sepsis secondary to pneumonia
tachycardia, tachypnoea, hypoxia, hypotension, fever, confusion
exam findings of pneumonia
> crackles - coarse
dull to percussion
bronchial breath sounds
pathogen causing pneumonia in pre-vaccinated infants
Group B strep occurs in pre-vaccinated infants, often contracted during birth as it often colonises the vagina.
most common cause of pneumonia
strep
most common viral cause of pneumonia
rsv
acute bronchitis vs pneumonia
> History: Sputum, wheeze, breathlessness may be absent in acute bronchitis whereas at least one tends to be present in pneumonia.
Examination: No other focal chest signs (dullness to percussion, crepitations, bronchial breathing) in acute bronchitis other than wheeze. Moreover, systemic features (malaise, myalgia, and fever) may be absent in acute bronchitis, whereas they tend to be present in pneumonia.
When should ab be used for acute brochitis
> systemically unwell, co-morbidities, CRP 20-100 (delayed prescription) or CRP > 100 - immediate
use doxycycline
Traffic light system - green
> normal colour, normal response to cues, awake
normal skin and eyes
no amber or red signs
Mx of fever - green
managed at home
Traffic light system - amber
> pallor
no smile, not responding to cues, decreased activity, wakes only w prolonged stimulation
nasal flaring, tachpnoea,
O2 sats less than 95% on air
crackles
reduced urine output
CRT over 3 seconds
dry mucous membranes
poor feeding
RR in amber kids (fever)
> > 50 in kidsaged 6 -12 months
40 In kids over 12 months
pulse in amber kids
> > 160 beats/minute, age <12 months
150 beats/minute, age 12-24 months
140 beats/minute, age 2-5 years
other features of the amber kid
• Age 3-6 months, temperature >=39ºC
• Fever for >=5 days
• Rigors
• Swelling of a limb or joint
• Non-weight bearing limb/not using an extremity
red (high risk) fever
> pale/ mottled/ ashen/ blue
no resp to cues, appears ill, does not wake or does not stay awake
weak cry
reduced skin turgor
resp signs of red fever
> resp rate > 60
moderate/ severe chest indrawing
red fever - other criteria
> under 3 months w a fever over 38 degrees
bulging foantanella
neck stiffness
non blanching rash
status epilepticus
focal neuro signs/ seizures
Mx of amber fever
> safety net or refer to paeds
red fever Mx
urgent referral to paeds
immunisation for whooping cough
> immunised at 2, 3, 4 months
and 3-5 yrs
immunisation does not offer lifelong protection
pregnant women
Features of whooping cough
> catarrhal phase: sim to VURTI, lasts 1-2 weeks
Paroxysmal phase: cough increases in severity
covalescent phase: cough subsides over weeks to months
Cough In whooping cough
> coughing bouts are usually worse at night and after feeding, may be ended by vomiting & associated central cyanosis
inspiratory whoop
may be spells of apnoea
persistent coughing may cause subconjunctival haemorrhages or even anoxia leading to syncope & seizures
diagnostic criteria for whooping cough
Whooping cough should be suspected if a person has an acute cough that has lasted for 14 days or more without another apparent cause, and has one or more of the following features:
> Paroxysmal cough.
> Inspiratory whoop.
> Post-tussive vomiting.
> Undiagnosed apnoeic attacks in young infants.
diagnosis of whooping cough
> nasal swab culture
PCR and serology
Mx of whooping cough
> infants under 6 months with suspect pertussis should be admitted
in the UK pertussis is a notifiable disease
an oral macrolide (e.g. clarithromycin, azithromycin or erythromycin) is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread
ab prophylaxis for household conacts
school exclusion for whooping cough
school exclusion: 48 hours after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics )
whooping cough vaccine is offered to pregnant women in weeks
Women who are between 16-32 weeks pregnant will be offered the vaccine.
meningitis vs meningococcal septicaemia vs meningococcal meningitis
> meningitis: inflammation of meninges
Meningococcal septicaemia refers to the meningococcus bacterial infection in the bloodstream.
Meningococcal meningitis is when the bacteria is infecting the meninges and the cerebrospinal fluid
Pathogens in meningitis
> meningococcus (neisseria)
strep pneumonia
neonates: group B strep - susually contracted during birth
presetation of meningitis
> fever
neck stiffness
vomiting
headache
photophobia
altered consciousness
seizures
what is a sign of meningococcal septicaemia
non blancing rash
signs of meningitis in neonates/ infants
non-specific signs and symptoms, such as hypotonia, poor feeding, lethargy, hypothermia and a bulging fontanelle.
Ix for meningitis
> lumbar puncture:
Under 1 month presenting with fever
1 to 3 months with fever and are unwell
Under 1 year with unexplained fever and other features of serious illness
Tests in meningitis
Kernigs, Brudzinkis
Kernigs test
involves lying the patient on their back, flexing one hip and knee to 90 degrees and then slowly straightening the knee whilst keeping the hip flexed at 90 degrees. This creates a slight stretch in the meninges. Where there is meningitis it will produce spinal pain or resistance to movement.
Brudzinskis test
involves lying the patient flat on their back and gently using your hands to lift their head and neck off the bed and flex their chin to their chest. In a positive test this causes the patient to involuntarily flex their hips and knees.
Community management of menigitis AND non blanching rash
immediately give IV or IM benzylpenicillin and transfer to hospital (in the case of penicillin allergy focus on transferring to hosp)
Hospital Mx of meningitis
> lumbar puncture for CSF
Blood culture
tests for meningococcal PCR
Ab
abs used in meningitis in the hosp
> Under 3 months – cefotaxime plus amoxicillin (the amoxicillin is to cover listeria contracted during pregnancy)
Above 3 months – ceftriaxone
add vancomyci if recent travel or prolonged ab exposure
steroids (to reduce hearing damage) - dexamethasone
Mx of menigitis - inform
PHE - notifiable disease
Post exposure prophylaxis for meningitis
> highest risk for those in contact w the child 7 days before symptom onset
single dose of ciprofloxacin or rifampicin
viral meningits causes
> HSV
VZV
enterovirus
Tx of viral meningitis
aciclovir
CSF analysis for meningitis
> the immune system releases neutrophils in response to bacteria and lymphocytes in response to viruses.
> image
Bacterial meningitis results
> Cloudy appearance (bacteria swimming in CSF)
high protein, low glucose (eating glucose)
high neutrophils
Viral meningitis results
> clear appearance (viruses aren’t alive)
proteins midly raised/ normal
normal glucose
high lymphocytes
negative culture
meningitis comps
> hearing loss
cerebral palsy
epilepsy
Mx of septic shock in kids
> IV fluids aggressively
if this fails, transfer to high dependency unit or ICU where ionotropes like noradrenaline can be used
Signs if sepsis
> prolonged CRT
fever or hypothermia
poor feeding
inconsolable/ high pitched cry/ weak cry
floppy
skin changes - cyanosis, mottled, pale, ashy
It is worth remembering that all infantsunder 3 monthswith a temperature of38ºC or above
need to be treated urgently for sepsis, until proven otherwise.
immediate management of paed sepsis
> O2 if shock or levels under 94%
IV access
blood tests and culture (FBC, U&E, CRP, clotting screen (INR), blood gas for lactate and acidosis)
urine dipstick
ab - within 1 hr
fluids if shock or if lactate above 2mmol/L
additional tests in sepsis
> CXR: pneumonia
abd US
LP: meningitis
Meningococal PCR
Serum cortisol: adrenal crisis
Sepsis - ab use
> continue for 5-7 days
stop when there is low suspicion of bacterial infection, patient is well, blood cultures and CRP results are negative at 48 hrs
Which vaccines are given to neonates at risk
> BCG if RF - (e.g. Tuberculosis in the family in the past 6 months).
hep B - birth, 4 weeks, and 1 yr
2 months - vaccines
> ‘6-1 vaccine’ (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B)
Oral rotavirus vaccine
Men B
3 months - vaccine
> 6 in 1
oral rotavirus vaccine
PCV
4 months - vaccibe
> 6 in 1
men B
12-13 months vaccines
> Hib / men c
MMR
PCV
men B
2-8 yrs vaccines
flu - annual
3-4 yrs vaccines
4-in-1 pre-school booster’ (diphtheria, tetanus, whooping cough and polio)
MMR
12-13 yrs vaccine
HPV
13-18 yrs vaccie
> 3 in 1 teenage booster - tetanus, diptheria, polio
men ACWY
females of child bearing age susceptible to rubella vaccine
mmr - exclude pregnancy before vaccinating and avoid pregnancy for one month after
pregnant females vaccies
> pertussis
DPT
influenza - inactivates
over 65s vaccines
> influenza - annual
pneumococcal
herpes zoster vaccine
> aged 65 and 70-79
which vaccine is not routinely given in the first 6 months of life
mmr
Most common cause of viral meningitis in adults
enterovirus (e.g. coxsackie)
men B schedule mneumonic
> B is second letter of the alphabet = 2 months
> second dose = double this -> 2 x 2 = 4 months
> Third dose = triple this -> 4 x 3 = 12 months
when not to do a LP
Suspected bacterial meningitis: an LP should not be done if there signs of severe sepsis or a rapidly evolving rash - possible raised ICP
> Do LP for meningitis BUT NOT meningococcal septicaemia
Cushings reflex
> bradycardia
HTN
CI TO LP!!!
who gets the HPV vaccine
All boys aged 12-13 (school year 8) are now offered the HPV vaccine as well as girls
when not to use dexamethasone in meningitis
> child under 3
meningococcal septicaemia: non blanchig rash
Prematurity =
> birth before 37 weeks gestation
under 28 weeks: extreme pretrm
28-32 weeks: very preterm
32-37 weeks: moderate-late preterm
associations of prematurity
> social deprivation, smoking, alc, drugs
overweight, underweight mother
twins
In women with a history of preterm birth or an ultrasound demonstrating a cervical length of 25mm or less before 24 weeks gestation there are two options of trying to delay birth:
> prophylactic vaginal progesterone: discourages labour
prophylactic cervucal cerclage - putting a suture in cervix to hold it closed
options to improve outcomes for preterm labour
> tocolysis with nifedepine
maternal corticosteroids
IV Mg sulphate
risks of prematurity
> resp distress syndrome
intraventricular haemorrhage
NEC
chronic lung disease, hypothermia, feeding problems, infection, jaundice
Hearing problems
retinopathy of prematurity
> imp cause of visual impairment in babies born before 32 weeks
overoxygenation e.g. during ventilation -> proliferation of retinal blood vessels (neovascularisation)
long term effects of prematurity
> chronic lung disease of prematurity
LDs
resp tract infections
CP
Neonatal apnoea
> very common in premature neonates
occurs in almost all babies under 28 weeks
brief periods of stopping breathing, oxygen desat, bradycardia
management of neonatal apnoea
> apnoea monitors
tactile stim to prompt baby to breathe
IV caffiene can be used to treat recurrent episodes
CXR of resp distress syndrome
> ground glass appearance
what is resp distress syndrome
> ffects premature neonates, born before the lungs start producing adequate surfactant - commonly below 32 weeks
not enough surfactant -> lung collapse -> inadequate gas exchange -> resp distress
incidence of resp distress reduced by
antenatal steroids ie. Dexamethasone in mother -> inc surfactant
Mx of resp distress
> intubation and V if severe
endotracheal surfactant
CPAP
O2
comps of neonatal resp distress
> pneumothorax
apnoea
retinopathy of prem more common
hearing and visual impairment
neonatal abstinence syndrome
> withdrawal symptoms happen in neonates of mothers who used substances in pregnancy
Withdrawal from most opiates, diazepam, SSRIs and alcohol occurs between after birth
3 – 72 hours
withdrawal from methadone and other benzos occurs between
24 hrs and 21 days
Symptoms of neonatal withdrawal
> tachypnoea
sweating
unstable T and pyrexia
poor feeding, vomiting, hypoglycaemia
irritable, high pitched cry, tremors, seizures
medical management of NAS
> Oral morphine sulphate for opiate withdrawal
Oral phenobarbitone for non-opiate withdrawal
SSRIs don’t need medical Tx
risks of SIDs
> usually within first 6 months
prematurity
Low birth weight
male baby
smoking in pregnancy
reducing risk of SIDS
> Baby on their back
keeping head uncovered
cot clear of toys and blankets
avoid smoking
avoid co sleeping
If co-sleeping avoid alcohol, drugs, smoking, sleeping tablets or deep sleepers
major RF for SIDs
> sleeping baby prone
bed sharing
prematurity
paternal smoking
hyperthermia - overwrapping or head covering
protective factoirs against SIDS
> BF
room charing but not bed sharing
use of dummies
MMR and pregnancy
> Pregnant women should not receive the MMR vaccination, as this is a live vaccine. Non-immune women should be offered the vaccine after giving birth.
features of congenital rubella syndrome
> Congenital cataracts
Congenital heart disease (PDA and pulmonary stenosis)
Learning disability
Hearing loss
chickenpox in pregnancy
> can lead to varicella pneumonitis, hepatitis or encephalitis
fetal varicella syndrome
severe neonatal varicella infection
checking for immunity to VZV in pregnancy
> prev CP: safe and immune
check IgG levels if doubt: positive indicates immunity
not immune: give IV VZV ab within 10 days of exposure
when is aciclovir used for CP in pregnancy
If the chickenpox rash starts in pregnancy, they may be treated with oral aciclovir if they present within 24 hours and are more than 20 weeks gestation.
congenital varicella syndrome
> cp within 28 weeks of gestation
fetal growth restriction
microcephaly, hydrocephalus, LDs
scars and skin issues following dermatomes
limb hypoplasia
cataracts
congenital CMV symptoms
> growth restriction
seizures
microcephaly
hearing loss and vision loss
triad of congenital toxoplasmosis
> intracranial calcification
Hydrocephalus
Chorioretinitis
congenital zika syndrome features
> Microcephaly
Fetal growth restriction
Other intracranial abnormalities, such as ventriculomegaly and cerebellar atrophy
congenital rubella, toxoplasmosis, CMV can all cause
Cerebral palsy
Newborn physical examination
> first by 72 hrs
second at 6-8 weeks old
The examinations include a full general physical examination & detailed examination of: eyes, heart, hips, and testes
physical exam of the newborn should involve
> congenital cataracts
congenital hd
ddh
undescended testes
At 6to8weeks, assess the baby’s
social smiling and visual fixing and following.
newborn blood spot
> at 5 days
sickle cell, CF, congenital hypothyroidism, PKU, MCADD, MSUD, IVA, GA1, HCU
Hearing test used in newborns
> otoacoustic emission
The presence of a soft echo indicates a healthy cochlea
if otoacoustic emission test is anbormal,
use auditory brainstem response test
jaundice in the first 24 hrs
> always pathological
can be caused by: rhesus haemolytic disease, ABO haem disease, GDP6 def, hereditary spherocytosis
jaundice in days 2-14
> common, usually physiological
more common in breastfed babies
If there are still signs of jaundice after 14 days (21 days if premature) a prolonged jaundice screen is performed, raised conjugated bilirubin could indicate
Biliary atresia
causes of prolonged jaundice (after 14 days)
> biliary atresia
hypothyroidism
breast milk jaundice
prematurity
congenital infections such as CMV
physiologyical jaundice
> fetuses have more fragile rbcs
can no longer excrete via placenta
This leads to a normal rise in bilirubin shortly after birth, causing a mild yellowing of skin and sclera from 2 – 7 days of age.
Babies with jaundice within 24 hours of birth need treatment for
sepsis if they have any other clinical features or risk factors.
jaundice in pre-emies
> higher risk of kernicterus - brain damage due to high levels of bilirubin
immature liver
what is hemolytic disease of the newborn
> Hemolysis and jaundice in the neonate caused by incompatibility between rhesus >antigens
When a woman that is recessed D negative becomes pregnant with a recess D positive child the mother will produce antibodies against this and has then become sensitized
This normally does not cause problems during the first pregnancy during subsequent pregnancies the anti D antibodies can cross a placenta if the if the fetus is rhesus positive this can lead to hemolysis
What occurs during hemolytic disease of the newborn
hemolysis which leads to anemia and high bilirubin levels
What are three important causes of prolonged jaundice
Billy Atresia hypothyroidism and GDP 6 deficiency
Investigations for neonatal jaundice
Full blood count and blood film for polycythaemia or anaemia
Conjugated bilirubin: elevated levels indicate a hepatobiliary cause
Blood type testing of mother and baby for ABO or rhesus incompatibility
Direct Coombs Test (direct antiglobulin test) for haemolysis
Thyroid function, particularly for hypothyroid
Blood and urine cultures if infection is suspected. Suspected sepsis needs treatment with antibiotics.
Glucose-6-phosphate-dehydrogenase (G6PD) levels for G6PD deficiency
Management of neonatal jaundice
> Management of neonatal jaundice depends on treatment threshold charts
Phototherapy is normally enough to correct it but exchange transfusions may be required (removing blood from the neonatal and replacing it with Donna blood )
kernecticus
> Type of brain damage that results from excessive bilirubin
Presents with a less responsive floppy drowsy baby with poor feeding
Causes permanent damage to the central nervous system causing cerebral palsy learning difficulties and deafness
Extra hepatic biliary atresia is more common in
Females than males
What is the most common type of bilibi atresia
Atresia of the left and right ducks to the level of the Porter Hepatis
what is the typical presentation of biliary atresia
> Patients typically present in the first few weeks of life with:
Jaundice extending beyond the physiological two weeks
Dark urine and pale stools
Appetite and growth disturbance
Signs of biliary atresia
> Jaundice
Hepatomegaly with splenomegaly
cardiac murmurs
Test results in Billery Atresia
> Total bilirubin may be normal, whereas conjugated bilirubin is abnormally high
Alpha 1 antitrypin deficiency may be a cause of cholesterol
Sweat chloride test cystic fibrosis
Management of Billy Atresia
Surgical intervention is the only definitive treatment - Kasai procedure. Liver transplanation may be required if this fails
Neonat and lung surfactant
> type two alveola cells start producing subactone between 24 and 34 weeks gestation - Free time babies have problems with reduced pulmonary surfactant
Cardio respiratory treat changes at birth
> A strong First breath is needed to expand previously collapsed alveoli adrenaline and cortisol are released in response to labor to stimulate respiratory effort
The baby’s first breath expands alveoli reducing pressure in the right atrium -> this then caused his closure of the foramen ivale
What drops after birth cause enclosure of the ductus arteriosus
> Prostaglandins drop after birth which causes closure of the ductus arteriosus which then becomes a ligamentum arteriosum
ductus venosus Closure
The ductus venosis stops functioning immediately after birth because the umbilical cord is clamped so there is no blood flow to umbilical veins . The doctors of the Gnosis clauses a few days later to become the ligamentum venosum
Features of congenital hypothyroidism
Prolonged neonatal jaundice, Paul feeding , Constipation tiredness slow growth and development
Management of congenital hypothyroidism
> Investigations include TFT thyroid ultrasound and thyroid antibodies
Levothyroxine in once a day
What kind congenital growth hormone deficiency be a result of
Growth hormone is produced by the anterior pituitary gland . Deficiency can be from genetic mutation GH1 or empty sella syndrome
Growth hormone deficiency may present at birth or in neonates with:
> Micropenis (in males)
Hypoglycaemia
Severe jaundice
GH def in older kids presents as:
> Poor growth, usually stopping or severely slowing from age 2-3
Short stature
Slow development of movement and strength
Delayed puberty
Growth hormone stimulation test
Measures response to medications that normally stimulate growth hormone release for example insulin glucagon
Management of GH deficiency
Dailysubcutaneousinjections ofgrowth hormone(somatropin)
Is what is congenital adrenal hyperpleasure caused by
> Congenital deficiency of 21 hydroxylase
This leads to under production of cortisol and aldosterone under too much androgens from birth
Inherited in an autosomal recessive pattern
What is the action of aldosterone
Released by the adrenal gland in response to renin. actson the kidneys to increase sodium resorption and increase potassium secretion into the urine
CAH pathophys
> 21-hydroxylase is the enzyme responsible for converting progesterone into aldosterone and cortisol
Extra progesterone is converted into testosterone instead -> Patient has low aldosterone low cortisol but abnormally high testosterone
severe CAH presentation
> females - ambiguous genitals w enlarged clitorus
Patients with more severe CAH present shortly after birth with hyponatraemia, hyperkalaemia and hypoglycaemia.
CAH pres in females
> tall, Facial hair, Absent peroidsDeep voice and early puberty
CH presentation in males
Tall, deep voice, Large penis, small testicles, early puberty
What are skin change to people with CAH get
hyperpigmentation because AP produces extra ACTH which is structurally similar to melanin
Management of CAH
> Hydrocortisone, fludrocortisone to replace aldosterone 4
what is associated w increased morbidity for CF
Chronic infection withPseudomonasandBulkholderiain CF are associated with increased morbidity and mortality - Bulkholderia is a CI against lung transplantation
rotavirus timings
Two months + three months
How does androgen insensitivity syndrome present
Groin swellings from undescended testes primary amenaria nor pubic hair. Breast development occurs
most common cause of ambiguous genitalia
CAH, AIS does not cause amb genitals
congenital rubella is associated w ? Murmur
patent ductus arteriosus, causing a machinery murmur.
congenital sensorineural deafness
> CMV: deafness, rubella: cataracts and deafness
what other causes of cyanotic heart disease
> right to left shunt
ASD, VSD, Patent ductus arteriousus, transposition if the great arteries
Eisenmenger syndrome.
Patients with ventral septal defect atrial septal defect or a patent doctors arteriosus are usually not cyntotic because the pressure on the left side of the heart is greater than the right side so blood flows into the right side. If pulmonary pressure increases beyond systemic pressure blood flows from right to left across the defect causing cyanosis
What are the complications of congenital heart disease
> Heart failure arrhythmias endorcarditis pulmonary hypertension eisenmenger syndrome
types of ASD
> Patent foramen ovale
ostium secondum and osteiyn primum
ASD
> blood moves from left -> RA
Overload in RA
blood still goes to lungs to get oxygenated si no cyanosis
right heart strain and pulmonary HTN
How does ASD lead to eismengers
> Pulm HTN -> increased right pressure -> pulm pressure > systemic pressure -> blood moves in opposite direction from right to left -> blood bypasses lungs leading to cyanosis
atrial septal defect pres
> often picked up on antenatal scans or newborn examination
can present in adulthood
dyspnoea secondary to pulm HTN and right sided HF
AF ir flutter
stroke in DVT patients
> ASD causes stroke in patients w DVT (clot enters systemic circulation and goes straight to brain)
ASD murmur
> systolic cresendo decresendo murmur loudesr at upper left sternal edge
fixed split second heart sound
Mx of ASD
> can be corrected surgically percutaneous transvenous catheter closure or open heart surgery
AC such as aspirin, warfarin, DOACs used to reduce risk of clots
conditions associated VSD
downs syndrome and turners syndrome
VSD murmur
> pansystolic mumur heard at left lower sternal edge in third and 4th ICS
increased risk of ? With VSD
IE. Give antibiotic prophylaxis during surgical
coarctation of the aorta =
> narrowing of the aorta usually around the DA
associated turners syndrome
pres of coarctation of the aorta
> systolic murmur below left infraclavicular area
four limb blood pressure: difference in BPs
left ventricular heave
ix for coarctation
CT angio
how can coarctation of the aorta present
> Percutaneous balloon angioplasty (stretching the stenosis), potentially with a stent inserted
Open surgical repair
medical management of HTN
Peripheral cyanosis vs central cyanosis
> peripheral: looking blue
central cyanosis when conc of hb exceeds 5g/dl
nitrogen washout test
> differentiate between cardiac vs non cardiac causes
The infant is given 100% oxygen for ten minutes after which arterial blood gases are taken.
A pO2 of less than 15 kPa indicates cyanotic congenital heart disease
causes of cyanosis congenital HD
> TOF
transposition of the great arteries
tricuspid atresia
mx of cyanotic congenital heart disease
> supportive care
prostaglandin E1 e.g. alprostadil - used to maintain patent ductus arteriosus
acrocyanosis
> often seen in healthy newborns
cyanosis around mouth and hands/ feet
occurs immediately after birth in healthy infants
features of TOF
> ventricular septal defect (VSD)
right ventricular hypertrophy
right ventricular outflow tract obstruction, pulmonary stenosis
overriding aorta
TOF - clinical features
> cyanotic episodes
ejection systolic murmur
cyanotic spells in TOF
> unrepaired TOF infants may develop episodic hypercyanotic ‘tet’ spells due to near occlusion of the right ventricular outflow tract
features of tet spells include tachypnoea and severe cyanosis that may occasionally result in loss of consciousness
they typically occur when an infant is upset, is in pain or has a fever
Chest XR findings of TOF
> CXR: Boot shaped heart
ECG: LVH
Mx of TOF
> Surgical repair
cyanotic episodes may be helped by beta-blockers to reduce infundibular spasm
when is patent DA more often
> usually, the ductus arteriosus closes with the first breaths due to increased pulmonary flow which enhances prostaglandins clearance
more common in premature babies, born at high altitude or maternal rubella infection in the first trimester
features of patent DA
> Left subclavian thrill
continuous ‘machinery’ murmur
large volume, bounding, collapsing pulse
heaving apex beat
Mx of patent DA
> Indomethacin or ibuprofen - given to the neonate inhibits prostaglandin synthesis (closes connection)
what is ebsteins anomaly
> low insertion of the tricuspid valve -> large atrium and large ventricles - atrialisation of the RV
lithium exposure in utero can cause
ebsteins anomaly
associations w ebsteins anomaly
> PFO, ASD, WPW
CFs of ebsteins anomaly
> cyanosis, prominent a waves in the distended JVP
hepatosplenomeg
tricuspid regurg
murmur of ebsteins anomaly
pansystolic murmur, worse on inspiration
ECG finding of ebsteins anomaly
RBBB -> widely split S1 and S2
ACEi as a teratogen
Renal dysgenesis
Craniofacial abnormalities
alcohol as a teratogen
Craniofacial abnormalities
aminoglycosides as a teratogen
Ototoxicity
