Neonatal Flashcards
What is classed as neonatal?
First 28 days of life
What does APGAR stand for in the APGAR scoring system?
Appearance
Pulse
Grimace
Activity
Respiration
What is the initial management of a sick newborn?
Stabilise temperature - 36.5-37.5
Airway and breathing - gentle support (open airway), consider oxygen as needed
Circulation - fluids and inotropes
Metabolic homeostasis - glucose management, correction of acid-balance
Antibiotics
What is the ongoing management for a sick newborn baby?
Diagnostic work up
Further support:
- ventilation
- drugs - vitamin K for haemorrhagic disease
- specific therapy
- surgery
- transfer
Care of family
How does sepsis present in a newborn baby?
Quiet
Poor feeding
Floppy
Tachypnoea
Apnoea
Tachycardia
Bradycardia
Temperature instability - high or low
Where can a baby get an infection?
Bloodstream -> bacteraemia/septicaemia
CNS -> Meningitis
Respiratory -> Pneumonia
Gastrointestinal -> Necrotising Enterocolitis
Urinary -> UTI
Skin
Bone
What are the most common bacterial organisms in newborns (most common to least)?
Group B Strep
E. Coli
Staphylococcus Aureus
Staph Epidermidis
Staph Capitis
Klebsiella Oxytoca
Listeria Monocytogenes
What are the best antibiotics for newborn babies?
Benzylpenicillin - gram +ve and gram -ve organisms
Gentamycin -> additional gram -ve cover
Cefotaxime is an alternative -> gram +ve and gram -ve
What are the common viral infections for newborns?
Toxoplasma
Syphilis
Hep B
Rubella
CMV
Herpes
What congenital abnormalities can syphilis cause?
bone abnormalities, anaemia, hepatosplenomegaly, eye problems, jaundice, meningitis, rashes
How is syphilis infection prevented in newborns?
Treatment for syphilis 30 days prior to delivery most important factor for reducing congenital infection.
What are the clinical signs of respiratory distress in newborns?
Tachypnoea
Recession
Grunting
Blue
Low saturations
What is the most common cause of respiratory distress in newborns?
Transient Tachypnoea of the newborn
What is TTN and how is it diagnosed and managed?
fluid in the lungs does not clear away. CXR shows fluid in the horizontal fissure. Resolves over the first 24 hours of life
What are some causes of respiratory distress in newborns?
TTN
Pneumothorax
RDS
MAS
Hypoxic Ischaemic Encephalopathy
Tracheo-oesophageal fistula
Diaphragmatic hernia
When can TTN most commonly occur?
In caesarean sections due to lack of adrenaline surge which switches off lung fluid production.
When does Respiratory Distress Syndrome occur?
Much more common in preterm infants.
Due to surfactant deficiency
Associated with IUGR, Maternal diabetes, infection, birth asphyxia, multiple births, PROM, meconium aspiration
What does RDS look like on a CXR and how is it treated?
CXR - ground glass appearance and air bronchograms
Treatment is with respiratory support and surfactant replacement.
What is Meconium Aspiration Syndrome and how does it present?
- MAS usually occurs following signs of foetal distress
- Can cause airway obstruction, inflammation, surfactant dysfunction
- In severe form it is linked with asphyxia and persistent pulmonary hypertension
What does MAS look like on CXR?
Patchyness across lungs
What is hypoxic ischaemic encephalopathy?
- Multi organ damage - brain, kidneys, liver, gut due to tissue hypoxia
- Primary event may be placental failure, cord prolapse, uterine rupture or other major event
What is the treatment and prognosis of hypoxic ischaemic encephalopathy?
- Poor apgar scores - active resuscitation required
- Neurodevelopmental sequelae - variable prognosis
- Therapeutic hypothermia improves neurodevelopmental outcomes
How does cardiac distress present in newborns?
Presents with tachypnoea, cyanosis not responsive to oxygen, murmur, femoral pulses may be weak or absent, circulatory collapse
When does hydrops foetalis occur?
rhesus disease - mum rhesus -ve and baby rhesus +ve
chromosomal
What is the condition associated with newborn baby and failure to adapt to postnatal life?
persistent pulmonary hypertension of the newborn (PPHN)
What are the critical congenital heart diseases of a newborn baby?
- Tetralogy of Fallot
- Transposition of the great arteries
- Coarctation of the aorta
- TAPVD
- Hypoplastic heart
What neurological conditions can be present in a sick newborn?
Microencephalopathy
Spina Bifida
What renal conditions can be present in a sick newborn?
Potter’s Syndrome - fatal - no treatments currently
What muscular conditions can be present in a sick newborn?
Myotonic Dystrophy
How does hypoglycemia occur in newborn babies?
Low birth weight and Small for gestational age -> reduced to reserves
IDM, medicines -> related to maternal disease
Evidence of more complex metabolic disease
What is the presentation of inborn errors of metabolisms in babies?
Presentations may be of acidosis, hypoglycaemia or jaundice.
What is the aetiology of neonatal sepsis?
- Early onset (EOS) - mainly due to bacteria acquired before and during delivery
- Group B streptococcus
- Gram negatives
- Late onset (LOS) - acquired after delivery (nosocomial or community sources)
- Coagulase negative staphylococci
- Gram negatives
- Staph. aureus
What are the risk factors for neonatal sepsis in premature infants?
- Immature immune system
- Intensive care environment
- Indwelling tubes and lines
What is the typical presentation of neonatal sepsis?
- Fever
- Reduced tone and activity
- Poor feeding
- Vomiting
- Respiratory distress orapnoea
- Tachycardia or bradycardia
- Hypoxia
- Jaundice within 24 hours
- Seizures
- Hypoglycaemia
What is the management of neonatal sepsis?
- Prevention - hand washing, vigilance, infection screening
- Antibiotics
- Supportive measures
What are the causes of respiratory distress in the newborn?
RDS
Metabolic -> acidosis, inborn errors of metabolism, hypoglycaemia
Haematological -> polycythaemia, blood loss/anaemia
Neurological -> seizures, intracranial bleed, withdrawal
Congenital -> congenital lung malformations e.g., CCAM
Anatomical abnormalities -> chest wall deformities
What is the pathophysiology of RDS?
- Inadequate surfactant leads to high surface tension within alveoli
- This leads to atelectasis (Lung collapse), as it is more difficult for the alveoli and the lungs to expand
- This leads to inadequate gaseous exchange, resulting in hypoxia, hypercapnia (high CO2) and respiratory distress
What is the typical presentation of RDS?
- Respiratory distress → tachypnoea, grunting, intercostal recessions, nasal flaring, cyanosis
- Worsens over minutes to hours until 2-4 days then gradual improvement
What is the management of RDS in a newborn?
- Maternal steroid
- Surfactant Replacement
- Ventilation (non-invasive preferred over invasive)
What is neonatal abstinence syndrome?
Refers to the withdrawal symptoms that happens in neonates of mothers that used substances in pregnancy
What substances cause NAS?
- Opiates
- Methadone
- Benzodiazepines
- Cocaine
- Amphetamines
- Nicotine or cannabis
- Alcohol
- SSRI antidepressants
What is the clinical presentation of NAS?
- CNS - irritability, tremors, seizures
- Vasomotor and respiratory - sweating, unstable temperature, tachypnoea
- Metabolic and GI - poor feeding, regurgitation/vomiting, hypoglycaemia
What is the management of NAS?
- Mothers that are known to use substances should have an alert on their notes so that when they give birth the neonate can have extra monitoring and management of NAS
- Babies are kept in hospital with monitoring on a NAS chart for at least 3 days (48 hours for SSRI antidepressants) to monitor for withdrawal symptoms
- The neonate should be supported in a quiet and dim environment with gentle handling and comforting
- Medical treatment options are available for moderate to severe symptoms.
What is defined as neonatal hypoglycaemia?
Defined as a BGL <2.6 mmol/L
What are the contributing factors to neonatal hypoglycaemia?
- Preterm
- Small for gestational age
- Low birth weight (<2.5kg)
- Infants of diabetic mothers
- Hypothermia
- Feeding
- Infection/Sepsis
- Neonatal abstinence syndrome
What is the presentation of a newborn with hypoglycaemia?
- lethargy
- Jitteriness
- Seizure activity
What is the management for a newborn with hypoglycaemia?
- early feed and keeping baby warm (36.5-37.5) helps prevent hypoglycaemia
- If safe to feed hypoglycaemic baby enterally, feed and assess (and repeat)
- If unsafe to feed baby requires IV glucose
- If recurrent - hypoglycaemia screen (when BM<2.6)
What is hydrocephalus?
Describes cerebrospinal fluid (CFS) building up abnormally within the brain and spinal cord
What causes hydrocephalus?
result of either over-production of CSF or a problem with draining or absorbing CSF
What is the presentation of hydrocephalus?
- enlarged and rapidly increasing head circumference
- Bulging anterior fontanelle
- Poor feeding and vomiting
- Poor tone
- Sleepiness
What is the management of hydrocephalus?
Ventriculoperitoneal shunt
What is necrotising enterocolitis?
Disorder affecting premature neonates, where part of the bowel becomes necrotic
What causes necrotising enterocolitis?
Serious intestinal injury to a relatively immature gut (e.g., premature baby being fed too early) resulting in perforation
How does necrotising enterocolitis present?
- intolerance to feed
- vomiting, particularly with green bile
- Generally unwell
- Distended, tender abdomen
- Absent bowel sounds
- Blood in stools
What can be seen on an abdominal x-ray in necrotising enterocolitis?
- dilated loops of bowel
- bowel wall oedema
- gas in bowel wall
- gas in peritoneal cavity (pneumoperitoneum) indicates perforation
What is the management of necrotising enterocolitis in newborns?
- Nil by mouth, clindamycin and cefotaxime
- Immediate referral to neonatal surgical team
What is intraventricular haemorrhage?
Bleeding into the ventricles inside the brain - in neonates occurs mainly in premature infants
What is the pathophysiology of intraventricular haemorrhage?
- Germinal matrix is the most common type → related to perinatal stress affecting the highly vascularised germinal matrix
- By 35-36 weeks gestation, the germinal matrix has essentially disappeared and thus the risk of haemorrhage is markedly reduced
How is intraventricular haemorrhage’s classified?
- Grade 1 and 2 - neurodevelopmental delay up to 20|%, mortality 10%
- Grade 3 and 4 - neurodevelopmental delay up to 80%, mortality 50%
What is jejunal atresia?
Congenital anomaly characterised by obliteration of the lumen of the jejunum
What is the typical presentation of jejunal atresia?
neonates typically present with abdominal distension and bilious vomiting within the first 24 hours of birth
What is the management of jejunal atresia?
surgical correction
What is malrotation?
Congenital anatomical anomaly that results from an abnormal rotation of the gut as it returns to the abdominal cavity during embryogenesis
What is the presentation of malrotation?
- most common presentation in the infant is midgut volvulus → presents with bilious green vomiting
- Up to 40% of patients with malrotation show signs within the first week of life
- 50-60% diagnosed by 1 month and 75% diagnosed by age 1.
What investigations are needed for malrotation?
upper GI contrast and follow through
What is the management of malrotation?
surgical correction
What is meconium ileus?
Refers to a neonatal bowel obstruction of the distal ileum due to abnormally thick and impacted meconium
What can cause meconium ileus?
Usually a manifestation of cystic fibrosis
What is an inguinal hernia?
Weakness in the muscle around the groin, resulting in a loop of bowel bulging through and causing a lump
What is the management of an inguinal hernia?
Surgical correction
What are the central causes of a floppy baby?
- Hypoxic ischaemic encephalopathy
- Intracranial haemorrhage
- Cerebral haemorrhage
- Chromosomal abnormalities e.g., Trisomy 21
- Congenital infections (TORCH)
- Acquired infections
- Peroxisomal disorders
- Drug Effects e.g., benzodiazepines
What are the spinal cord causes of a floppy baby?
- Birth trauma especially breech delivery
- Syringomyelia
What causes of floppy baby are related to anterior horn cells?
- Spinal Muscular Atrophy
- Pompe’s Disease
What neuromuscular junction causes are there fore floppy baby?
- Myasthenia Gravis
- Infantile botulism
What is the presentation of floppy baby?
- rag doll
- lack of head control
- increased range of movement
- frog legged
- feel like they’ll fall out your grasp
- possibly breathing difficulties
What investigations are needed for floppy baby?
**Bloods:**
- Genetics - NGS
- Metabolic
- Congenital infection screening
- Creatinine kinase
******Neurology review******
- EEG
- EMG
****Imaging****
- cranial USS
- MRI
What is the management of floppy baby?
- Early intervention - respiratory and feeding support, physiotherapy, occupational therapy, patient involvement
- Regular review of growth and development - clinic follow up, health visitor and GP communication
- Some specific management may be available depending on cause e.g., RNA targeted therapy for spinal muscular atrophy
- Early diagnosis is key as there is often a critical window for treatment (e.g., in PKU, SMA)
