Neonatal Flashcards
What are some causes of Hypoxic-ischaemic encephalopathy?
excessive/prolonged uterine contractions
placental abruption
cord compression (shoulder dystocia, cord prolapse)
maternal hypotension or hypertension
IUGR
failure to breath
How does mild hypoxic-ischaemic encephalopathy present?
irritable, response, hyperventilation, impaired feeding
How does moderate hypoxic-ischaemic encephalopathy present?
marked abnormalities of tone and movement, can’t feed and may have seizures
How does severe hypoxic-ischaemic encephalopathy present?
no normal spont movements or response to pain
tone in the limbs may flunctuate between hypo and hypertonia
seizures prolonged
multi-organ failure
How would you manage an infant with hypoxic-ischaemic encephalopathy?
respiratory support
EEG
anticonvulsants
fluid restriction
treat hypotension
treat hypoglycaemia and hypocalcaemia
*mild hypothermia (wrapping infant in cooling blanket) can reduce brain damage if started with 6 hrs of brth
What are examples of some soft tissue injuries?
Caput Succedeneum
Cephalhaematoma
Chignon
Subaponeurotic haemorrhage - severe blood loss, hypovolaemic shock and coagulopathy
How does Erb palsy present? What nerve is damaged?
arm lies straight and limp
hands pronated
fingers flexed
Brachial nerve
How would a facial nerve palsy present?
unilateral, facial weakness on crying but eye remains open
may need methylcellulose drops
What causes respiratory distress syndrome?
deficiency of surfactant leading to widespread alveolar collapse and inadequate gas exchange
What are risk factors for respiratory distress syndrome?
male sex
diabetic mothers
Caesarean section
second born of premature twins
Clinical features of respiratory distress syndrome?
tachypnoea
laboured breathing with recession
nasal flaring
expiratory grunting
cyanosis
How would you manage respiratory distress syndrome?
prevention during pregnancy: maternal corticosteroids to induce fetal lung maturation
oxygen
assisted ventilation
exogenous surfactant given via endotracheal tube
What are some common conditions seen in preterm infants?
Pneumothorax
Patent ductus arteriosus
Haemorrhage
Necrotising Enterocolitis
Retinopathy of prematurity
Cerebral Palsy
Where is a common sign that brain haemorrhages occur in pre term infants?
germinal matrix above the caudate nucleus
What puts infants at higher risk of necrotising enterocolitis?
Drinking cow’s milk formula rather than only breast milk
How does necrotising enterocolitis present?
intolerant to feeds
milk aspirated - vomiting which may be bile-stained
abdomen becomes distended
stool sometimes has fresh blood
What investigation would you carry out in suspected necrotising enterocolitis? What would you see?
X-ray
dilated bowel loops (often asymmetrical in distribution)
bowel wall oedema
pneumatosis intestinalis (intramural gas)
portal venous gas
pneumoperitoneum resulting from perforation
air both inside and outside of the bowel wall (Rigler sign)
air outlining the falciform ligament (football sign)
What is treatment for necrotising enterocolitis?
stop oral feeding
broad-spec abx
parenteral nutrition needed
surgery for perforation
How do you define bronchopulmonary dysplasia? What causes it?
infants who require oxygen post-gestational age of 36 weeks
pressure and volume trauma from artificial ventilation, oxygen toxicity and infection
What would you see on x-ray of someone with bronchopulmonary dysplasia?
widespread areas of opacification
fibrosis
lung collapse
cystic changes
overdistension of lungs
How do you treat bronchopulmonary dysplasia?
prolonged artificial ventilation
CPAP
short course corticosteroid
What should given when discharging a premature baby?
iron as supplementation or in preterm formula for 6 months
multivitamins
prophylaxis against RSV if bronchopulm dysplasia (pavlizumab)
What problems do prem infants tend to develop later in life?
cerebral palsy
trouble with fine motor skills
concentration
behaviour problems
abstract reasoning
multi-tasking
What is a common non-pathological cause of neonatal jaundice?
marked physiological release of haemoglobin from the breakdown of RBC because of high Hb conc. at birth
RBC life span of newborn infants are shorter than adults
hepatic bilirubin metabolism is less efficient in the first few days of life
What are some pathological causes/consequences of neonatal jaundice?
haemolytic anaemia
infection
metabolic disease
liver disease
kernicterus
What is kernicterus?
encephalopathy resulting from the deposition of unconjugated bilirubin in the basal ganglia and brainstem nuclei
*bilirubin is fat-soluble and can therefore cross BBB
How does kernicterus present?
lethargy
poor feeding
irritability
increased muscle tone (lie with arched back, opisthotonos)
seizures
coma
Long-term complications of kernicterus?
choreoathetoid cerebral palsy
learning difficulties
sensorineural deafness
What are causes of jaundice <24 hrs?
rhesus haemolytic disease
ABO haemolytic disease
hereditary spherocytosis
glucose-6-phosphodehydrogenase
What causes jaundice 2-14 days
physiological
usually breastfed babies
dehydration
infection
What are causes of prolonged jaundice?
biliary atresia
hypothyroidism
galactosaemia
urinary tract infection
breast milk jaundice
congenital infections e.g. CMV, toxoplasmosis
What should investigations should be done if there is jaundice beyond 14 days?
PROLONGED JAUNDICE SCREEN
conjugated and unconjugated bilirubin: the most important test as a raised conjugated bilirubin could indicate biliary atresia which requires urgent surgical intervention
direct antiglobulin test (Coombs’ test)
TFTs
FBC and blood film
urine for MC&S and reducing sugars
U&Es and LFTs
What should be done if jaundice is suspected?
In first 72 hrs all babies should be checked for jaundice clinically and if clinically jaundiced, a transcutaneous measurement made
How would you manage jaundice?
phototherapy
exchange transfusion
What are some causes of respiratory distress in term infants?
transient tacypnoea of the newborn
meconium aspiration
pneumonia
pneumothorax
milk aspiration
persisten pulmonary hypertension of the newborn
diaphragmatic hernia
What causes transient tachypnoea of the newborn? What would you see on an X-ray?
delay in resorption of lung liquid, common after C-section
fluid in horizontal fissure
What are the effects of meconium aspiration on the fetus?
mechanical obst of lungs
pneumonitis
pre-disposing to infection
lungs over-inflated
pneumothorax
persistent pulmonary hypertension of the newborn
What are risk factors for pneumonia?
prolonged rupture of membranes
chorioamnionitis
low birthweight
What is associated with persistent pulmonary hypertension of the newborn?
birth asphyxia
meconium aspiration
septicaemia
respiratory distress syndrome
How does PPHN present?
cyanosis
pulm oligaemia
How would you manage PPHN?
mechanical ventilation and circulatory support
inhaled NO
sildenafil
How does diaphragmatic hernia present?
resp distress
failure to respond to resus
apex beat and heart sounds displaced to right side
What is biggest complication assoc. with diaphragmatic hernia?
pulmonary hypoplasia
What are the differences between early infection and late infection?
early - <48 hrs after birth, bacteria that have infected birth canal
late - >48 hrs, source of infection is the victims environment
Antibiotics are given to cover which organisms in an early infection?
group B strep
listeria
gram positive (amox or benzylpenicillin)
gram negative (gentamicin)
Antibiotics are given to cover which organisms in an late infection?
flucloxacillin and gentamicin
if doesn’t work > vancomycin
What can be used to monitor responsiveness to treatment in infection?
blood cultures
CRP
Risk factors for group b strep infection?
preterm
prolonged rupture of membranes
maternal fever during labour
mater chorioamnionitis
previously infected infant
What organisms can cause conjunctivitis in neonate? What are the specific treatments?
Staph/Strep - neomycin
Gonococcal (gram stain discharge immediately - can lead to blindness ) - cephalosporin
Chlamydia trachomatis -erythromycin
How would a herpes simplex virus infection present in a neonate?
anytime up to 4 weeks of age
localised herpetic lesions on the skin or eye
encephalitis
disseminated disease
Hypoglycaemia usually seen in what groups of neonates?
IUGR
preterm
diabetes mums
large-for-dates
hypothermic
polycythaemic
How would hypoglycaemia present in a neonate?
jitteriness
irritability
apnoea
lethargy
drowsiness
seizures
How would you manage a hypoglycaemic infant?
prevented by early and frequent milk feeding
IV glucose
glucagon
hydrocortisone
If a neonate is having a seizure, what should be ruled out first?
hypoglycaemia
meningitis
Causes of seizures in neonates?
HIE
Cerebral infarction
septicaemia/meningitis
metabolic (glucose, sodium, calcium, magnesium)
intracranial haemorrhage
drug withdrawal
infection
kernicterus
What is cleft lip and palate associated with?
maternal anticonvulsant use
Who should be involved in the care for a baby with cleft lip and palate?
Plastics
ENT
Paediatrician
Orthodontist
audiologist
speech therapist
How does oesophageal atresia present?
persistent salivation
drooling
cough and choking during feeding
yanotic episodes
What are causes of small bowel obstruction in neonates?
atresia or stenosis of duodenum
atresia or stenosis of jejunum
malrotation with volvulus
meconium ileus
meconium plug
What are causes of large bowel obstruction in neonates?
hirschprung
rectal atresia
What are the steps to neonatal resuscitation?
- Dry baby and maintain temperature
- Assess tone, respiratory rate, heart rate
- If gasping or not breathing give 5 inflation breaths*
- Reassess (chest movements)
- If the heart rate is not improving and <60bpm start compressions and ventilation breaths at a rate of 3:1
What are prenatal. perinatal and postnatal causes of cerebral palsy?
Prenatal - cerebral malformation, TORCH infection, metabolic
Perinatal - hypoxia, intrapartum trauma, prematurity complications
Postnatal - head trauma, stroke, meningitis
How does cerebral palsy present?
spasticity = UMN signs, rigidity, hyperreflexia/tonia, delayed milestones, poor co-ordination, persistent primitive reflexes
epilepsy
audiovisual development
resp problems
poor growth
APGAR
Score Pulse Respiratory effort Colour Muscle tone Reflex irritability 2 > 100 Strong, crying Pink Active movement Cries on stimulation/sneezes, coughs 1 < 100 Weak, irregular Body pink, extremities blue Limb flexion Grimace 0 Absent Nil Blue all over Flaccid Nil
A score of 0-3 is very low score, between 4-6 is moderate low and between 7 - 10 means the baby is in a good state
