Introduction to Neonatology Flashcards
small for dates causes: maternal
smoking
maternal pre-eclamptic toxaemia
small for dates causes: foetal
chromosomal e.g. edwards
infection e.g. CMV
small for dates causes: placental
abruption
small for dates causes: other
twin problems
common problems in small for dates babies
- Perinatal Hypoxia
- Hypoglycaemia
- Hypothermia
- Polycythaemia
- Thrombocytopenia
- Hypoglycaemia
- Gastrointestinal problems (feeds, NEC)
- RDS, Infection
long term problems in small for dates babies
- Hypertension
- Reduced growth
- Obesity
- Ischaemic heart disease
name 2 common respiratory problems in preterm babies
respiratory distress syndrome
bronchopulmonary dysplasia
respiratory distress syndrome: prevention
antenatal steroids
respiratory distress syndrome: treatment
surfactant
early extubation
N-CPAP
minimal ventilation
bronchopulmonary dysplasia: features
- Overstretch by volu-baro-trauma
- Atelectasis
- Infection via ETT
- O2 toxicity
- Inflammatory changes
- Tissue repair - scarring
bronchopulmonary dysplasia: treatment
o Patience
o Nutrition & growth
o Steroids (!)
minor respiratory problems in premature neonates and treatment
apneoa
irregular breathing
desaturations
caffeine
N-CPAP
brain complications in premature neonates
intraventricular haemorrhage
periventricular leucomalacia
post haemorrhagic hydrophalus
what is the most common limiting factor for good term prognosis in premature babies
intraventricular haemorrhage
intraventricular haemorrhage: prevention
AN steroids
intraventricular haemorrhage: treatment
symptomatic
drainage
patent ductus arteriosus
• Pressure in Ao > PA = L R shunt
• Additional blood to pulmonary circulation
o Over perfusion of lungs
o Lung oedema
• Steal from systemic circulation
o Systemic ischaemia
• Consequences
o Worsening of respiratory symptoms
o Retention of fluids (low renal perfusion)
o Gastrointestinal problems (GE ischaemia
GI problems in premature neonates
NEC necrotising entero colitis
nutrition
necrotising entero colitis
• Ischaemia and inflammatory changes
• Necrosis of bowel
• Surgical intervention is often required
• Conservative management is sometimes possible
o Antibiotics and parenteral nutrition
nutrition issues in premature babies
Preterm babies have enormous nutritional requirements that are unparalleled anywhere else in medicine. Patients often triple their size during their hospital stay. Building new functional tissues from compounds provided artificially.
outcome of extreme prematurity
The outcome is unpredictable at time of birth, and often very uncertain even on discharge home. Ultrasound of brain by the end of the 1st week. Surprising deterioration in cognitive and behavioural between 2nd and 6th years. Also, some unexpected improvement between 2nd and 6th year of life. Extremely limited data on subjective quality of life in adulthood.
- 1/3 die
- 1/3 have normal life or mild disability
- 1/3 have moderate or severe disability for lifetime
- 1 in 6 is entirely normal at 6 years old
- Subjective quality of life was not different in ex preterm compared to ex term controls
foetal circulation
- Oxygenated blood via umbilical vein – ductus venosus
- Some blood via foramen ovale to left atrium – left ventricle – aorta
- Some of blood to right ventricle – pulmonary artery – patent ductus arteriosus from PA to Ao
- Saturations SaO2 in foetal body is 60-70%
ductus arteriosus
The ductus arteriosus protects the lungs against circulatory overload. Allowing the right ventricle to strengthen. It carries low oxygen blood.
ductus venosus
The ductus venosus is the foetal blood vessel connecting the umbilical vein to the IVC. The blood flow through it is regulated via a sphincter. It carries mostly oxygenated blood.
normal vital signs of a full term new born: BP
- 1 hr 70/44
- 1 day 70 +/- 9 / 42 +/-12
- 3 days 77 +/- 12 / 49 +/- 10
normal vital signs of a full term new born: RR
- 30-60/min
* Periodical breathing
normal vital signs of a full term new born: HR
- Normal 120-160 bpm
- Tachycardia > 160 bpm
- Bradycardia <100 bpm
thermoregulation in neonates
In the womb maternal thermoregulation maintains the babies temperature. New-born babies lack shivering thermogenesis thus need a metabolic production of the heat. Brown fat is well innervated by sympathetic neurones. Cold stress leads to lipolysis and heat production.
loss of heat in neonates
• Radiation o Heat dissipated to colder objects • Convection o Heat loss by moving air • Evaporation o We are born in the water • Conduction o Heat loss to surface on which baby lies
physiological jaundice: when does it occur
2-3 days of life
physiological jaundice: when does it disappear
7-10 DOL in term
up 21 in premature
physiological jaundice: how does it happen
75% bilirubin comes from haemoglobin. Metabolised, conjugated in liver. Bilirubin is lipid soluble thus crosses haemato-encephalic barrier. At high concentrations cause irreversible changes in the brain – kernicterus
physiological jaundice: how can it be treated
Blue light converts bilirubin to water soluble form and increases oxidation of bilirubin.
fluid balance in term newborns
Full term infant is able to maintain fluid / electrolyte balance. Weight loss up to 10% is normal. Loss is due to: shift of interstitial fluid to intravascular and diuresis. It is normal not to pass urine for the first 24 hrs!
• Less fat in body composition • Increased loss through kidney: o Slower GFR o Reduced Na reabsorption o Decreased ability to concentrate or dilute urine • Increased Insensible Water Loss (IWL) o Via immature skin and breathing o Physiological IWL is 20-40 ml/kg/day but could be up to 82 ml/kg/day in 750-1000 g
physiological anaemia of the newborn
- RBC production is 10% of in uterus DOL 7
- Born with - Hb 15-20 g/l
- Week 10 - Hb 11.4 g/l
- Increase production of Erythropoietin
- Week 20 - Hb 12.0 g/l
anaemia of prematurity
o Reduced erythropoiesis.
o Bloodletting – most important cause!
common post natal problems: skin colour
jaundice
pallor
plethora
cyanosis
common post natal problems: skin rashes
benign milia miliaria erythema toxicum neonatorum infections sebaceous naevus
common post natal problems: skin birthmarks
o Capillary haemangiomas o Mongolian blue sports o Port wine stains o Stork marks o Giant melanocytic naevi o Café au lait spots
what can exacerbate physiological jaundice?
dehydration
onset of jaundice when is always pathological?
24 hrs of life
neobron pallor
Pallor is a clinical sign and not a diagnosis. It suggests anaemia and may be congenital or acquired. Decrease in haemoglobin may be secondary to bleeding internal or external. Decreased production by bone marrow or increased destruction of RBC may also cause anaemia. Disseminated intravascular coagulopathy can also cause it. The most common cause of anaemia in preterm is iatrogenic secondary to blood sampling.
newborn plethora
Plethora is a condition marked by an excess volume of blood causing swelling and a reddish complexion. A cause of this might be polycythaemia which has implications in terms of blood viscosity.
newborn milia
This is white papules on the tip of the nose caused by hyperplastic sebaceous glands. The effect of the transplacental hormones. The disappear with desquamation
newborn miliaria
Miliaria are the result of obstruction to immature sweat glands. They are commonly seen secondary to thermal stress, crops of lesions over the face, scalp and trunk. Miliaria crystallina are superficial vesicles with a diameter of 1-2 mm. The skin is not inflamed. Miliaria rubra aka prickly heat are papules and pustules from obstruction in the mid-epidermis.
newborn erythema toxicum
The cause this maculo popular rash is unknown but it mostly clears after 1-2 week. It occurs in 30-70% of normal term neonates. It is very rare in the pre term. No treatment is required.
newborn skin indections
These are relatively rare. Non benign pustular rashes with the commonest cause being staph aureus. Consider herpes.
newborn sebaceous naevus
These are hamartomatous lesions sensitive to androgens. Androgens are produced during puberty causing the lesions to become larger and more wart like. There is risk of malignant degeneration (basal cell carcinoma) in adulthood therefore elective removal should be considered.
newborn capillary haemangiomas
Also known as strawberry naevus and intradermal haemangiomas. A cluster of dilated capillaries appear within the 1st month. They are raised and bright red with discrete edges. They can be found on any part of the body. They usually regress after 1st year. They vary in severity from salmon patch
newborn mixed haemangioma
These have a deep vascular component. If vision is under threat then they require treatment. There are a vascular anomaly. Histologically they are abundant endothelial cells with narrow vascular channels. They are the commonest tumours of the eyelids and orbits in childhood.
newborn mongolian blue spots
There are blue-grey pigmentations of the skin. They often affect the lower back and buttock. They result from an accumulation of melanocytes. They are very common is races with pigmented skin. Less obvious as the skin darkens
port wine stains
The port wine stain is dark purple in colour and is located most
frequently on the face in the area of distribution of the fifth cranial nerve. There is no tendency for this type of haemangioma to regress spontaneously. Sturge–Weber syndrome is an occasional associated malformation. Also associated with Kippel Trenaunay Weber.
Also known as naevus flammeus these are present at birth. They may be flat or slightly raised. Caused by dilated, mature capillaries in the superficial dermis. They do not regress. Treatment is with cosmetic cover; good results can be achieved with the pulsed dye laser.
newborn stork marks
Also known as naevus simplex these are a light colour capillary dilatation. Commonly found at the back of the neck. May also be found along the midline of the face. They gradually fade within the 1st 2 years.
This is a very common flat pink lesion, present at birth. It is usually located on the forehead, eyelids, occiput, neck or midline of the back. It may be V-shaped on the forehead/occiput. Facial lesions fade, occipital tend not to. The lesions are not pathological so there is no active management needed
newborn giant melanocytic naevus
These are a large area of pigmentation that often becomes hairy later. Rarely there may be a malignant change. Lesions are present at birth, at any site, size and number, but often fade at least to some degree, occasionally dramatically. Patients may develop new lesions after birth. MRI brain and whole spine if more than one lesion, to look for associated neurological melanosis/ structural abnormalities/tumours. Cosmetic implications.
café au lait spots
These are common in new-borns and can range from 2mm to 20cm in size. They are typically on unexposed skin. They form as a result of increased melanin in melanocytes, and epidermal cells. they may increase in number with age. 6 or more greater than 0.5cm consider neurofibromatosis.
causes of jaundice: 1st 24 hrs
haemolytic - G6PD spherocytosis
TORCH
causes of jaundice: 2nd day - 3rd wk
o Physiological ( gone after 1st wk ) o Breast milk o Sepsis o Polycythaemia o Cephalohematoma o Crigler-Najjar Syndrome o Haemolytic disorders
causes of jaundice: after 3rd week
o Breast milk
o Hypothyroidism
o Pyloric stenosis
o Cholestasis
investigations of newborn jaundice
- Bilirubinometer
- Se bilirubin (+ conjugated fraction)
- FBC
- Blood film
- Blood group, Coomb’s test
treatment of newborn jaundice
- Treat underlying cause
- Hydrate
- Phototherapy – NICE guideline charts
- Exchange transfusion
- Immunoglobulin
conjugated jaundice in the newborn
- Rare cause of neonatal jaundice
- Worry if conjugated fraction > 20 and > 20%
- Need to exclude biliary atresia
- HIDA scan investigation
- Surgery more likely to succeed if performed < 6 weeks of age
- High chance that liver transplant will be required
Kernicterus Acute Bilirubin Encephalopathy: phase 1
first few days of life
decreased alertness
hypotonia
decreased feeding
Kernicterus Acute Bilirubin Encephalopathy: phase 2
variable onset and duration
hypertonia of extensor muscles
retrocolis
opisthotonus
Kernicterus Acute Bilirubin Encephalopathy: phase 3
Infants > 1 week of age
hypotonia
Kernicterus Chronic Bilirubin Encephalopathy
- 1st year – hypotonia, hyperreflexia, delayed acquisition of motor milestones
- Extrapyramidal – athetosis, chorea, upper limbs > lower limbs
- Visual – ocular movements, upward gaze
- Auditory – high frequency hearing loss, delayed language
- Cognitive – not severely affected
- Opisthotonus from kernicterus. This is now rarely seen in developed countries
- Macroscopic appearance of brain in a term infant with kernicterus.
babies at risk of hypoglycaemia
• Limited glucose supply o Premature babies o Perinatal stress • Hyperinsulinism o Infants of diabetic mothers • Increased glucose utilisation o Small and large for gestational age o Hypothermia o Sepsis
symptoms of hypoglycaemia in babies
- Jitteriness
- Hypothermia
- Temperature instability
- Lethargy
- Hypotonia
- Apnoea, irregular respirations
- Poor suck / feeding
- Vomiting
- High pitched or weak cry
- Seizures
- Asymptomatic
what level is hypoglaemia in babies
<2.6 mmol/l
when can bedside testing of BM be inaccurate
o At low or high levels
o When there is poor perfusion
o When there is polycythaemia
what babies are vulnerable to hypothermia
low birth weight and those requiring prolonged resuscitation
tongue ties
- Short +/- thickened frenulum
- Attached anteriorly base of tongue
- Mostly no treatment necessary
- Restriction of tongue beyond the alveolar margins or heavy grooving tip of tongue and/or feeding is affected frenotomy
GI problems in neonates
- Vomiting
- Posseting
- Mucous vomits
- Gastro-oesophageal reflux
- Cow’s milk protein intolerance
- Bilious vomiting
- Failure to pass meconium
- Bloody stools
- Blood in vomit
airway obstruction in babies: main symptoms
stridor
retractions
airway obstruction in babies: sites
nose
mouth and jaw
larynx or trachea
bronchi
areas to assess for retractions in babies
substernal
subcostal
intercosta
suprasternal
causes of airway obstruction in babies: laryngomalacia
o Floppy upper larynx
o Stridor +/- feeding problems
o Gets worse at 2-3 months and most resolve without treatment
causes of airway obstruction in babies: trachiomalacia
o Floppy tracheal cartilage
o Stridor worst when crying, coughing, feeding
o Most commonly affects distal 3rd of trachea
o Most improve by 2 years
causes of airway obstruction in babies: bronchomalacia
o Weak bronchial cartilage
o Stridor, wheeze, and dyspnoea
o More likely to need CPAP +/- tracheostomy
murmus in newborns
Murmurs are common but most are benign. Timing is important. Assess colour, perfusion and respiratory status. Note location, type and radiation of murmur. Record oxygen saturations and 4 limb blood pressure. Perform a CXR and Echo.
cyanosis in newborns
- Always think sepsis
- Acrocyanosis
- Examination, especially cardiac
- Monitor ECG, saturations, BP
- Oxygen
- Blood gas and baseline bloods
- CXR
- Echo
- Consider prostin and referral to cardiology
arrhythmias in newborns
- Foetal arrhythmia
- Maternal autoantibodies
- SVT
- Heart block
- ECG with rhythm strip
- Echo
- Discuss with cardiology
choanal atresia in newborns
Choanal atresia is a congenital malformation where there is a failure to develop a communication between the nasal cavity and the nasopharynx. It can be unilateral and more rarely, bilateral.
• Nasal obstruction
• Baby is cyanotic at rest. “pinks up” with crying
• If bilateral may need oral airway or endotracheal intubation
• Oral airway sizes
o 00 for small infants
o 0 for term or large infants
pierre robin sequence in newborns
Very small jaw with tongue obstruction and possible cleft palate. Place prone to move the tongue forward. For respiratory distress insert 2.5mm ET tube nasally with tip visible at back of throat, humidified O2 or use CPAP, may need endotracheal intubation
cleft lip
70% of cleft lip cases also have a cleft palate. It can range from incomplete, small gap in lip, to complete where it continues onto the nose. It can be unilateral or bilateral. Left sided unilateral is most common. 85% of bilateral cleft lips have palatal involvement. Maxillary and medial nasal processes fail to merge, usually around 5 weeks gestation.
cleft palate
The 2 plates of the skull forming the hard palate fail to merge by 9 weeks’ gestation and can occur after lip closure. If the soft palate is also cleft then most times a cleft lip is present. Can be complete (soft and hard palate involved) or incompletes (hole in the roof of the mouth, soft palate involved.
issues with a cleft lip/palate
• Feeding issues o Special bottles and teats o Can still attempt breast feeding • Airway problems • Associated anomalies o Need hearing screen o Need cardiac echo o Remember trisomies
congenital cataracts
- Lens opacification
- If undetected early could lead to blindness
- May require no treatment
- May require lens removal and artificial lens
retinoblastoma in children
Retinoblastoma affects 1 in 20,000 children, which is equivalent to about 45 cases per year in the UK. More than 90% of cases are diagnosed before 5 years of age. Children with bilateral retinoblastoma present earlier (median age 8 months) than the unilateral form (median age 28 months). Presenting signs include leukocoria (white pupillary reflex), strabismus, red eye and reduced vision. Tumours are bilateral in 30% of cases. Five percent have deletions of chromosome 13q14 and present with dysmorphic features and failure to thrive.
renal pelvis dilatation in newborns
This is a common antenatal finding. It is important to prevent renal damage from Vesico-ureteric reflux. There is a protocol for investigation and treatment. Scans at birth and 6 weeks +/- prophylactic antibiotics.
newborn female genitalia problems
• Skin tags o Common o No action required • Urinary meatus • Clitoris o Relatively larger in preterm or IUGR infants
Mucosal skin tags are a fold or continuation of the mucosa from the vaginal wall and is often seen in new-born girls. It shrinks and disappears within the first week of life.
Vaginal bleeding or pseudo-menstruation is a normal effect of withdrawal from maternal hormones. It can last from 48 hrs to 6 days.
newborn male genitalia problems
- Undescended testes – requires follow up
- Micropenis - <2.5cm term, refer if worried
- Hypospadias – proximally displaced urethral meatus
- Chordee – ventral curvature of the penis
- Torsion – usually antenatal, clinical emergency if acute
- Hydrocoeles – benign and no treatment required
- Inguinal hernias – more common in preterms, require surgery
Undescended testes occurs in 2% of births. 1.5% by 3 months: retractile, palpable and impalpable. Referral for surgery age 1 – 2 years.
The average stretched penile length at birth is about 4 cm. 90% of term boys between 2.4 and 5.5cm. refer if seems small.
A hypospadic urethra opens anywhere along a line (the urethral groove) running from the tip along the underside (ventral aspect) of the shaft to the junction of the penis and scrotum or perineum. In 1st degree the urethral meatus opens on the underside of the glans penis in about 50-75% of cases. With second degree the urethra opens on the shaft. Around 20% of cases. 30% of cases are 3rd degree where the urethra opens on the perineum. 3rd degree can be associated with chordee or with undescended testes.
Chordee exists where there is a ventral curvature of the penis. It can occur along with hypospadias but is can also be isolated.
Torsion is uncommon but treatment is required within 6 hours for testis to remain viable. A hard tender testis with sometimes bluish discoloration. Most neonatal cases the testis is already necrotic. Urgent surgical referral.
Hydrocoeles are a frequent finding in new-borns. Important on palpation to identify the normally small testicles (approximately 1 cm) as separate entities from the large, smooth-walled fluid collections of hydrocoeles. In contrast to inguinal hernias, common (non-communicating) hydrocoeles cannot be reduced as the fluid is in an enclosed space. Transillumination may be used to assist in making a diagnosis
Hernias are common, reducible. Irreducible hernias may strangulate. Early referral for paediatric surgery
ambiguous fenitalia
• Clearly indeterminate sex
o Genitalia clearly ambiguous
• Apparent male
o Bilateral non-palpable testes in full term new-born
o Separation of the scrotal sacs with hypospadias.
o Hypospadias concomitant with undescended testicle
• Apparent female
o Clitoral hypertrophy
o Foreshortened vulva with a single opening
o Inguinal hernia containing a solid mass ( likely to be a gonad)
what to do in ambiguous genitalia
- Reassure the parents their child is healthy but, you are not sure of the sex and will ask an experienced doctor to see the baby.
- Parents may wish to restrict visitors until the gender has been assigned.
- Discuss relocation to single room with the midwife.
- Never guess or say (looks like a male or a female)
- Ask the Neonatal Registrar/Consultant to see immediately
- Dr Mayo, Consultant Paediatrician, & Mr Driver, Consultant in Surgical Paediatrics, would like to be involved early.
investigations in ambiguous genitalia
• Serum electrolytes and glucose (may need to repeat daily)
• Chromosome analysis
o Remember phenotype more important than genotype
• Pelvic/abdominal ultrasound scan to determine pelvic structures and the presence or absence of gonads.
• 17-hydroxyprogesterone
• Serum for Testosterone
spinal dimples in the newborn
Benign spinal dimples are indentations in the skin on the lower back just above the buttocks. They are present at time of birth and usually small and shallow. >2% of babies have such dimples. Almost all of these are very minor and do not need any medical treatment.
They can reveal a more serious abnormality involving the spine and/or spinal cord, such as spina bifida occulta which is the least serious form of spina bifida. Dimples may also be indicative of a possible kidney problem. If the dimple is large, red, swollen, off midline, higher than sacral area, pigmented, tender or accompanied by fluid Ultrasounds, and MRI’s are all used to make a clear diagnosis and rule out a more serious condition.
cephalohaematomas in the newborn
These are localised swelling over one or both sides of the head that becomes maximal in size by the 3rd or 4th DOL. They are soft, non-translucent swellings. Limits are those of one of the cranial bones – usually parietal. Haemorrhage is beneath the pericranium. No treatment is required, and resolution occurs in 3-4 weeks. Occasionally, if the haematoma is very large the increased haemolysis results in increased or prolonged jaundice. No association with intracranial bleeding.
caput succedaneum
Serosanguinous, subcutaneous fluid collection with poorly defined margins caused by the pressure of the presenting part of the scalp against the dilating cervix during delivery scalp swelling that extends across the midline and over suture lines and associated with head moulding does not usually cause complications and resolves over the first few days.
facial palsy in the newborn
Unilateral facial nerve palsy is the most common peripheral nerve injury, with an incidence as high as 1.4 per 1000 live births . Injury can result from direct trauma from forceps or from compression of the nerve against the sacral promontory while the head is in the birth canal. Decreased facial movement and forehead wrinkling on the side of the palsy, eyelid elevation, and flattening of the nasolabial folds and corner of the mouth. Crying accentuates the findings, with the most obvious sign being asymmetrical movement of the mouth. The side that appears to droop when crying is the normal side.
asymmetric crying facies in the newborn
Differentiated from facial nerve palsy in that the eye and forehead muscles are unaffected. Congenital deficiency or absence of the depressor anguli oris muscle which controls the downward motion of the lip. Left side of the mouth is affected in nearly 80% of cases. Lip asymmetry may also be apparent when the infant smiles. Other facial features are symmetrical. Frequently an isolated finding. However, may be associated with cardiovascular, musculoskeletal, genitourinary, respiratory defects or 22q11 deletion.
talipes in the newborn
Medial (varus) or lateral (valgus) deviation of the foot is often positional and requires no treatment other than physiotherapy. Fixed talipes requires more vigorous manipulation, strapping, casting or possibly surgery. Babies with significant talipes may also have developmental dysplasia of the hips.
developmental dysplasia of the hip
• Shallow acetabulum results in femur slipping out of the socket • Risk factors o Breech > 36 weeks o First degree relative with DDH o Multiple birth o Female o 1st child o Large birth weight • Examination o Leg length o General movement of the legs o Groin creases o Ortolani test o Barlow test o Ultrasound
features of trisomy 21
• Dysmorphism o Low set ears, downward slanting palpebral fissures, epicanthic folds, single palmar creases, wide sandal gap • Hypotonia • Cardiac defects • Learning problems • Haematological problems • Thyroid problems Enquire about serum screening in pregnancy. The child typically present as a floppy neonate with up slanting palpebral fissures, flat facial profile, large fontanelle(s), poor suck and cardiac murmur. 50% have congenital heart disease and there is a twofold increase for all congenital anomalies. Median survival is close to 50 years unless there is a significant cardiac or other malformation. Mean IQ for young adults is 45–50 but this declines later due to early onset dementia.
Edwards (18) and patau (13) syndromes
Occur in 7,900 livebirths (increases with maternal age). Genetic aetiology/pathogenesis 47XXorXY+18. Most are due to an error during meiosis and 85% are of maternal origin. The aetiology
is associated with increased maternal age. Prematurity is common and many trisomy 18 foetuses are lost spontaneously during pregnancy. The birth weight is low (mean 2240 g) and the head shape is abnormal with a prominent occiput. Limb abnormalities are found with contractures of the fingers, short hallux, prominent heels and sometime a radial deficiency of the forearms. 90% have a congenital heart defect and the sternum is short. Cleft lip and palate, exomphalos and diaphragmatic hernia are common additional malformations
reasons for term admissions to NNU
sepsis TTN meconium aspiration cardiac hypoglycaemia hypothermia birth asphyxia hypoxic ischaemic encephalopathy • Oesophageal atresia/fistula • Duodenal atresia and other GI atresias • Causes of failure to pass stool • Abdominal wall defects • Diaphragmatic hernia
newborn sepsis symptoms
- Baby pyrexia or hypothermia
- Poor feeding
- Lethargy
- Early jaundice
- Hypoglycaemia
- Hyperglycaemia
- Asymptomatic
risk factors for newborn sepsis
- PROM
- Maternal pyrexia
- Maternal GBS carriage
management of presumed sepsis in the newborn
- Admit NNU
- Partial septic screen (FBC, CRP, blood cultures) and blood gas
- Consider CXR, LP
- IV penicillin and gentamicin 1st line
- 2nd line iv vancomycin and gentamicin
- Add metronidazole if surgical/abdominal concerns
- Fluid management and treat acidosis
- Monitor vital signs and support respiratory and cardiovascular systems as required
commonest causes of neonatal sepsis
• Group B streptococcus • E-coli • Listeria • Coag-neg staphylococci (if lines in situ) • Haemophilus influenzae • GBS Sepsis o Early onset – birth to 1 week o Late onset or recurrence – up to 3 months o Symptoms – may be non-specific o May have no risk factors o Complications Meningitis, DIC, pneumonia and respiratory collapse, hypotension and shock o Prognosis – 4 to 30% mortality
ToRCH may result in
o IUGR o Brain calcifications o Neurodevelopmental delay o Visual impairment o Recurrent infections
transient tachypnoea of the newborn
TTN is self-limiting and common. It presents within the 1st few hours of life. Clinically the child will be grunting, tachypnoeic, oxygen requirement with normal blood gases. Pathophysiology is a delay in the clearance of foetal lung fluids. Management is supportive with antibiotics, fluids, oxygen and airway support.
Meconium Aspiration
Meconium is inhaled into the lungs. Risk factors include: post-dates (aged placenta), maternal diabetes, maternal hypertension and difficult labour. Symptoms are: cyanosis, increased work of breathing, grunting, apnoea and floppiness. Investigations: blood gas, septic screen and CXR.
Meconium Aspiration treatment
• Suction below cords • Airway support o Intubation and ventilation • Fluids and antibiotics IV • Surfactant • NO or ECMO
Meconium Aspiration prognosis
- Most do well
- Some develop PPHN
- There is an associated mortality
investigation of the blue baby
- Examination and history
- Sepsis screen
- Blood gas and blood glucose
- CXR
- Pulse oximetry
- ECG
- Echo
- (hyperoxia test)
Differential cardiac diagnoses for the blue baby
- TGA
- Tetralogy of Fallot
- TAPVD
- Hypoplastic left hear syndrome
- Tricuspid atresia
- Truncus arteriosus
- Pulmonary atresia
treatment of the blue baby
- ABC
- Inotropes as required
- Fluid resuscitation
- Respiratory support (care with O2)
- Prostin (PGE2)
- Nitric oxide
- Cardiology referral
hypoglycaemia in NICU
If requires admission to NNU may still manage with enteral feeds. Monitor blood glucose and start IV 10% glucose. Increase fluids and glucose concentration (central IV access). Glucagon and hydrocortisone
hypothermia in NICU
If unable to maintain temperature on PNW admit and place in incubator. Sepsis screen and antibiotics. Consider checking thyroid function. Monitor blood glucose.
jaundice in NICU
In severe jaundice an admission for intensive phototherapy and/or exchange transfusion may be needed. Incubator and IV fluids may be required.
causes of birth asphyxia
- Placental problems
- Long, difficult delivery
- Umbilical cord prolapse
- Infection
- Neonatal airway problem
- Neonatal anaemia
hypoxic ischaemic encephalopathy: primary phase
o Acute injury = primary energy failure
o Minutes to hours
hypoxic ischaemic encephalopathy: latent phase
o Reperfusion
o 6-15 hours
hypoxic ischaemic encephalopathy: secondary phase
o Delayed injury = secondary energy failure
o Hours to days
hypoxic ischaemic encephalopathy: management
- Supportive
- Fluid restriction (avoid cerebral oedema)
- Monitor for renal and liver failure
- Respiratory support
- Cardiac support
- Treat seizures
- Therapeutic hypothermia improves outcomes especially in moderate group
hypoxic ischaemic encephalopathy: cooling/further management
- Baby cooled to 33 degrees for 72 hours
- Then rewarmed slowly over 12 hours
- Sedated for cooling
- Monitored with CFAM
- Cranial ultrasounds
- MRI at 7-10 days
- Neurodevelopmental follow up
caues of failure to pass stool in the newborn
• Constipation • Large bowel atresia • Imperforate anus o +/- fistula • Hirschsprung’s disease • Meconium ileus o Think cystic fibrosis
diaphragmatic hernia in the newborn
- 1 in 2500 births
- 90% on left
- Male > female
- Can be syndromic
- Usually pulmonary hypoplasia
- Intubation at birth
- Respiratory support
- Surgery
- (ECMO)
