Neonatal Flashcards
What is the NIPE?
Newborn exam: diagnose health problems soon after birth. All should have within 72 hours (ideally at 6-24 hours to allow period of physiological transition).
Screening may be carried out by trained midwives or by paediatricians & is governed by the National Newborn & Infant Physical Examination (NIPE) screening program.
Acceptable obs for a neonate?
HR 120-160
Systolic 50-70 mmHg
RR 40-60
Temp 36.5-37.5°C
What are different steps of the NIPE? (15)
- General Inspection
- Head
- Face
- Ears
- Mouth
- Eyes
- Neck & clavicles
- Arms & hands
- Chest
- Abdomen
- Groin & genitals
- Pelvis & legs
- Feet
- Spine
- Neuro: tone, head lag, cry, sucking, symmetrical movement & reflex (Moro & stepping)
What should be checked in the ‘general inspection’ part of the NIPE?
Colour: polycythaemia (redness), jaundice, cyanosis, traumatic cyanosis (tight wrapped cord causing local petechiae & cyanosis - no central cyanosis).
Skin: stawberry naevi, Erythema Toxicum Neonatorum (~50%!), mongolian blue spot, milia (milk spots), naevus simplex, benign pustular melanosis, congenital melanocytic naevi, port wine stain, collodion baby, napkin rash
Obs
What should be checked when doing head examination in NIPE?
Sutures palpable and fontanelles soft and flat (tense/bulging = raised ICP, sunken = dehydration).
Head Shape: moulding = overlapping skull bones due to passage through birth canal, usually resolves 2-3 days. Plagiocepahly + brachycephaly - both forms of ‘flat head syndrome’ (~1 in 5 babies, most cases no concerns– improves over time). Craniosynostosis (rare, premature fusion of bones + palpable ridged suture > abnormal growth of head). Scaphocephaly (premature fusion of sagittal suture - form of craniosynostosis).
Bleeds: caput succedaneum, cephalohaematoma, subhaleal haemorrhage, EDH and intracerebral bleed (very rare, may cause life-threatening bleeding. Most likely traumatic delivery but may also be associated with NAI).
- Largest circumference: take largest of 3 readings; should be 0.1-0.2cm accuracy.
When do the fontanelles close?
Anterior closes 18-24 months (closure at birth due to microcephaly or moulding). Posterior closes birth-2 months.
What is caput succedaneum?
Oedematous swelling + bruising on presenting part. Associated with ventouse, serosanginous and subcutaneous, crosses suture line (effusion overlies periosteum) pitting oedema.
Resolves without Tx (few days) but may need analgesia.
What is a cephalohaematoma?
Subperiosteal swelling limited to surface of one bone (usually parietal), does not cross suture lines (but can be bilateral!).
Common in prolonged second stage deliveries + assisted deliveries. Usually mild, but severe cases risk jaundice or anaemia. Maximal on the 2nd day + resolves over days-weeks. Resolution linked with calcification which can lead to it feeling like there is a prominent ring of bone around a central defect. These may exacerbate jaundice.
What is a subgaleal haemorrhage?
Diffuse swelling of scalp (boggy appearance), may represent serious blood loss (bleeding between periosteum + scalp galea aponeurosis).
Rare, but potential to be serious (hypovolaemia). May be associated with traumatic delivery e.g. vacuum extraction or with coagulopathies in the infant.
What should be checked when doing face examination in NIPE?
Abnormal facies: e.g. Fetal Alcohol, Down’s, Turner’s, Cushing, Noonan, Weaver, Sotos and Russell-Silver Syndromes
Facial nerve palsy: forceps injury or birth trauma – often manifests with asymmetrical facial expression when crying (care must be taken to ensure infant can completely close eye of affected side!!)
What should be checked when doing ear examination in NIPE?
Position, shape & skin tags / pits / abnormalities.
Pre-auricular skin tags + pre-auricular skin pits - both often normal but can be associated with hearing loss or renal abnormalities
What should be checked when doing mouth examination in NIPE?
Open to check for swellings
Gently insert finger to assess hard + soft palate
(if soft palate cleft: specialist cleft teams who support feeding + plan surgical correction)
Asses suck reflex
Neonatal teeth may need review by dentist as some can become loose and cause airway hazard
What should be checked when doing eye examination in NIPE?
Bilateral red reflex (+6 setting, 12 inches from face)
Absence may indicate retinoblastoma (white reflex) or congenital cataracts - 2 week referral to ophthalmologist
If not co-operative, placing baby over mothers’ shoulder will encourage baby to fully open eyes.
Subconjunctival haemorrhage: small bleeds due to delivery – resolve spontaneously
What should be checked when doing neck/clavicle examination in NIPE?
Palpate clavicles for evidence of birth trauma (fracture relatively common birth injury, especially in assisted delivery e.g. shoulder dystocia)
Check for signs of brachial plexus injury (more common in breech & shoulder dystocia)
Erb’s palsy: injury to C5-C6 peripheral nerves, weakness in elbow flexion & supination
Klumpke’s Palsy: injury to C8-T1 – weak extensors of arm and intrinsic muscles of hand, may be associated with Horner’s syndrome
Examine skin folds of neck for evidence of infection or other abnormalities
What should be checked when doing arm/hand examination in NIPE?
- Brachial Pulses (+ exclude humeral fracture)
- Palmar Creases: transverse palmar crease is found in ~5%; inherited trait associated with Down’s syndrome and other genetic disorders, but can reassure in absence of other abnormalities.
- Fingers: polydactyly often hereditary and most commonly isolated finding. Whole, functional fingers may be kept but finger segments surgical removed. Post-axial polydactyly usually isolated, but pre-axial (rare) is more likely to be related to an underlying medical condition. Syndactyly usually an isolated finding with no impact on function (easily missed so check carefully), but more severe cases can significantly affect function. Polysyndactyl: combination of both extra digits + webbing.
Also check hypoplasia / aplasia / formation of nail beds.
- Grasp Reflex
What should be checked when doing chest examination in NIPE?
- Inspection: symmetry & pulsation
Neonatal gynaecomastia:
- Apex heart: heaves & thrills
- Auscultate 4 regions
- Breath sounds: Noisy breathing common in newborns but should not be increased WOB. Stridor can indicate laryngomalacia, aortic vascular ring, haemangioma nodule of the vocal cord or external compression from a neck lump.
What is neonatal gynaecomastia / how is it managed?
Breast tissue in up to 90% neonates (transfer of maternal oestrogen + progesterone). Enlarged tissue: normal response to falling oestrogen at end of pregnancy (triggers prolactin release from neonatal pituitary).
Usually normal, associated with milky discharge (usually resolving ~few weeks & squeezing out increases complications including infection).
Persistence >1-2 months may indicate pituitary tumour.
Usually bilateral, may be asymmetrical; if unilateral consider abscess or mastitis, especially if heat or erythema.
In the NIPE, what should be considered when assessing for murmurs?
Not all neonates with congenital heart disease will have detectable murmurs and not all those with murmurs will have congenital heart disease.
Risk factors: CHD in first degree relative, T21 or abnormality on USS.
If murmur, reassuring signs are: o Pink, no cyanosis, with normal pre-and-post ductal oxygen saturations o No respiratory distress o Quiet, intermittent, positional murmur o Feeding well o Normal four limb blood pressures
Common causes of pathological murmurs: PDA + VSD. If murmur detected >24 hours of age, senior opinion must be sort: local guidelines likely to include senior review, ECG, pre-and-post ductal saturations (4 limb BP not useful). If suspicion of pathology ?inpatient echo. If not suspected, follow up by consultant or GP.
What should be checked when doing abdo examination in NIPE?
- Inspection
Cord: clean & dry with no redness to surrounding skin
Symmetry / distention / masses - Palpation
Iliac fossae > hypochondrial regions (ensures enlarged liver/spleen not missed). Feel independently for spleen & liver (liver: soft edge up to 1cm below costal margin). Ballot kidneys (often easy to feel in first day of life).
What should be checked when doing groin + genital examination in NIPE?
- Femoral Pulses
Note any difference in quality compared to brachial pulses. In coarctation: pulses absent or difficult to feel (radio-femoral delay is not present as a sign in infancy). If absent: ECHO, 4 limb BPs / saturations & refer to cardiac surgeons.
- Hernial orifices
Umbilical Hernia (usually benign but can be associated with genetic syndromes e.g. Beckwith-Wiedemann Syndrome), Inguinal Hernia.
- Genitalia & anus
Establish if passed urine & meconium. Anorectal malformation: check anus for patency (note: passage of meconium does not equate to patent anus or anus in correct place – anorectal malformations are commonly associated with urogenital malformations)
Undescended testes (first degree relative cryptorchidism - risk factor)
Ambiguous genitalia
Hypospadias
Scrotal & groin swellings
Palpable Bladder: requires prompt evaluation as may be sign of urinary obstruction (e.g. due to posterior urethral valves in males).
How should undescended testes be managed?
Palpable but undescended needs routine follow-up, if not descended at 2 years old will likely require surgical correction to reduce chance of later malignacy. If impalpable on just one side laparoscopy required to identify position. If bilateral undescended & impalpable, urgent review for ambiguous genitalia required.
What does ambiguous genitalia indicate?
CAH or other endocrine abnormalities - urgent senior review. Genetic, biochemical + endocrine work ups are to ascertain cause + aid decisions regarding the sex of the baby. Informing parents as soon as concerns arise reduces the emotional trauma associated with these complex cases.
What types of hypospadias are there and how is it managed?
May be glandular (on the glans penis), distal (on the penile shaft), or proximal (on the scrotum)
Always important to ensure there is a good urinary stream, educate the parents not to circumcise their baby (foreskin is often used in the repair), and ensure paediatric surgical follow up. In case of proximal hypospadias, may be necessary to complete chromosomal and endocrine workup, as severe cases may be difficult to differentiate from ambiguous genitalia.
How are suspected hydroceles managed?
Scrotal swellings that transilluminate: normally resolve spontaneously but may be followed up for parental reassurance. Care should be taken not to miss an inguinal hernia as these require surgical referral. If doubt about whether lump is inguinal hernia or hydrocele, USS helpful.
What causes neonatal withdrawal bleeds / discharge?
Exposure to maternal hormones can make the outside of the vagina (i.e. labia majora and clitoris) a little swollen and prominent, and can cause a thick, milky discharge.
More dramatically, at 2-3 days of age there may be a little bit of bleeding caused by withdrawal of the hormones exposed to in the womb – can reassure that this will be the first and last menstrual period until puberty. Requires no treatment.
What should be checked when doing pelvis + leg examination in NIPE?
Relaxed on firm surface. When pelvis stabilised, hip + knee flexed 90 degrees.
Barlow: stabilise non-test hip + adduct hip being tested. Push femur into acetabulum (pressure towards bed, downward pressure on knee) – posterior movements suggest it is possible to dislocate the hip out of the acetabulum. Dislocation will give a ‘click’
Ortolani: stabilise pelvis by firmly holding symphysis pubis and coccyx between thumb & middle finger. Index finger of other hand on greater trochanter + abduct hip: palpable ‘clunk’ signifies relocation of posteriorly dislocated hip.
Also check: equal length upper & lower leg segments, exclude femur fracture
Examine skin creases – differences may indicate hip asymmetry
How should hip abnormalities on NIPE be managed?
If congenital dislocation of hip: hip USS + urgent review (2 weeks) in neonatal or specialist hip clinic for follow up. Treatment in first instance is with Pavlik harness.
Developmental dysplasia of the hips (1-2/10,000): risk factors first degree relative with hip problem as baby or young child (requiring splint, harness or operation), breech at or after 36 weeks (or at delivery if before 36 weeks).
If normal examination but risk factors present: hip USS within 6 weeks. If ‘clicky’ but not dislocated or dislocatable then local practice varies regarding USS.
What should be checked when doing feet examination in NIPE?
Mobility
Talipes Equinovarus: fully dorsiflex feet to shin and invert & evert to 90°. Fixed talipes = inversion of feet which cannot be manually corrected with dorsiflexion. Requires referral to physiotherapy. Positional talipes which can be brought to a normal position with very little pressure may not need treatment beyond gentle straightening exercises which can be done by the parents with each nappy change.
Skin creases & toes: count toes & check sandal gap
What should be checked when doing neuro examination in NIPE?
- Spine: ventral suspension position: midline defects down back
Stalk mark / naevus flamius on nape of neck is a common normal finding. Pigmentations or unusual lesions potentially significant: may suggest underlying spinal defect
Buttocks parted to check for sacral dimples – may be normal but dimples that are deep, discharging, or associated with abnormal neurology / skin discolouration are more likely to indicate spinal cord tethering > MRI / USS.
Hairy tufts may be associated with spina bifida occulta.
- Tone
- Head Lag
- Cry
- Sucking
- Symmetrical movements
- Reflexes (stepping, morrow)
Main reflexes in neonates?
Moro (birth - 3/4 months)
grasp (birth - 4/5 months)
rooting (birth - 4 months)
stepping (birth - 2 months)
What is early jaundice?
presenting <24 hours
Causes: rhesus incompatibility, ABO incompatibility (Group O mothers most at risk), G6PD deficiency, hereditary spherocytosis, infection (always suspect)
May be more severe (significant) in: preterm, sepsis, severe haemolysis (due to Rh-incompatibilty, ABO incompatibility, G6PD deficiency, spherocytosis) and bruising (cephalohaematoma or subgaleal haemorrhage – blood in haematoma breaks down).
What is physiological jaundice?
Presenting after 24 hours + resolving 2 weeks (or in 21 days if preterm).
Usually presents day 2 – 3. VERY common: most babies appear enteric (yellow) to some extent. Although may appear very yellow, usually not a problem.
However, very high bilirubin can cross BBB & cause kernicterus. If physiological may still require phototherapy (especially as infants may have become more tired and feeding may suffer). Rarely: may require immunoglobulin or exchange transfusion.
Term neonate can have level >300 on day 4 of life and not require any treatment
Causes:
Breastfeeding jaundice (unclear aetiology, resolves without treatment or complication, continue breastfeeding)
Polycythaemia: babies have naturally high packed cell volume (PCV); more red cells = greater breakdown
Resolving cephalohaematoma
How does phototherapy work?
Light in blue region most effective
Converts insoluble trans-bilirubin > photoisomers (cis-bilirubin) that can be excreted into the bowel (without requiring conjugation by liver).
What is prolonged jaundice?
> 14 days or >21 days if preterm
Causes: BREASTFEEDING jaundice (most common but diagnosis of exclusion), BILE DUCT obstruction (e.g. biliary atresia, choledochal cysts), HYPOTHYROIDISM, UTI, neonatal hepatitis, metabolic issues (e.g. galactosaemia, alpha-1-antitrypsin deficiency, glucogen storage disease), genetic (e.g. CF, trisomy 21/18), toxic (drugs, TPN).
- Bile duct obstruction e.g. biliary atresia (congenital absence of biliary tree): most important condition to exclude, requires urgent surgical assessment : pale stools + dark urine worrying: implies limited or no passage of bile into gut, delay in diagnosis > worse prognosis (does not resolve spontaneously, often requires liver transplant unless prompt identification + surgical correction)
- Hypothyroidism : possible presentation but should usually picked up earlier as part of screening programs
- UTI: undiagnosed may present with jaundice as only symptom
- Neonatal hepatitis: liver inflammation > biliary flow obstruction
- Physiological / breast feeding jaundice: most common cause of prolonged jaundice, but diagnosis of exclusion
What causes breastmilk jaundice?
Some bilirubin in the bowel reverts to the unconjugated form in the presence of bacteria. Conjugated form then reabsorbed by the enterohepatic circulation.
This can be exaggerated if exclusively breastfed > breastmilk jaundice (most common form of prolonged jaundice).
How should jaundice be investigated?
All require transcutaneous bilirubinometer check (heel prick also possible). If < 2 weeks old: plot onto treatment threshold graph.
May also consider (based on suspicion) blood film & FBC (red cell anomalies, inflammatory markers), DAT or Coombs test (for haemolysis), CRP (for infection but can be normal in neonates despite overwhelming sepsis!), blood cultures (if starting Abx must be done first).
Ask: pigmentation of stools & dark urine, whether infant is thriving, mode of feeding, Fhx of jaundice.
Prolonged jaundice: check Total Bilirubin including the conjugated fraction: (↑ conjugated fraction suggests biliary atresia).
Prolonged jaundice screen: FBC, blood film, DAT / Coombs, CRP, blood cultures, thyroid function, liver function (including conjugated bilirubin) & clean catch or catheter urine sample for bacteria.
How is jaundice managed?
If <2 weeks old: plot onto treatment threshold graph. Separate graphs for 38+ weeks and for each week between 23 & 37 weeks.
- UV Phototherapy: maximum skin exposure, keep eyes covered, ensure good feeding & regular monitoring of bilirubin – rebound bilirubin should be checked (after phototherapy stopped)
- Exchange transfusion: done in small aliquots over several hours to a total of 2x baby’s blood volume (replaces 85% of baby’s blood), usually requires venous & arterial access
- IV immunoglobin (haemolytic disease)
Prognosis / complications of jaundice?
Well treated, then good prognosis with no long-term effects, kernicterus is in theory completely avoidable with early detection + treatment
Kernicterus: encephalopathy resulting from deposition of unconjugated bilirubin in the brain. Unconjugated bilirubin crosses BBB & binds irreversibly to neuroreceptors in basal ganglia + brainstem nuclei > permanent neurological effects (e.g. choreoathetoid CP, learning disability, deafness). Occurrence rare in developed countries as neonatal jaundice tends to get identified & treated early. Mild cases present with poor feeding & lethargy, whilst more severe cases are associated with irritability, hypertonia, seizures & coma.
Consequences: lethargy, poor feeding, irritability, hypertonia, seizures, coma, CP + learning disability, deafness. Long-term effects of kernicterus mimic a parkinsonian picture due to effects on basal ganglia and severe developmental delay.
Why is neonatal sepsis so important?
Leading cause of neonatal mortality worldwide
High index of suspicion + early treatment when suspected.
Blood inflammatory markers highly unreliable in neonates (especially in early stages of sepsis).!
What is early onset neonatal infection?
When is it treated?
Onset within 48 hours, usually vertical transmission
Babies often given Abx based on pre-delivery risk factors:
o Invasive GBS in previous pregnancy
o Current pregnancy: maternal GBS colonisation, bacteriuria or infection
o Prolonged rupture of membranes
o Preterm birth
o Intrapartum fever or suspected chorioamnionitis
o Suspected or confirmed infection in other baby if multiple pregnancy
o Suspected or confirmed invasive bacterial infection in mother
How may early onset neonatal infection present? What are the likely causes?
May present non-specifically, but possible signs: temp instability, poor feeding, vomiting, respiratory distress, apnoeas, brady/tachycardia, shock, hypo/hyperglycaemia, irritability, lethargy / drowsiness, seizures, jaundice (particularly first 24 hours) + ↓ urine output
Likely: Group B Strep (most common cause of serious bacterial infection in 1st week of life) other strep species, coliforms
Rarer: Listeria, Klebsiella, Pseudomonas
Investigations and management for neonatal infection?
Blood cultures, baseline inflammatory markers (if raised, or worrying clinical signs: further assessment + lumbar puncture). If respiratory signs: CXR
If possible infection: broad-spectrum Abx e.g. gentamicin + benzylpenicillin.
Duration dependent on: bacteria isolated from baby or mother, whether any rise in inflammatory markers, and whether symptoms present at onset or during treatment
Minimum duration 36-48 hours, pending culture results
What is late onset neonatal infection? What causes it?
> 48 hours
More likely environmental, particularly if inpatient (staff / visitors, indwelling lines, poor aseptic technique in performing neonatal procedures).
GBS can present after 48 hours (including those discharged to community)
Staphylococcal infections (including aureus) are increasing: Coagulase-negative Staphylococcus = most common infecting organism on neonatal unit, particularly if long lying venous catheters (although also part of normal skin flora). Coliforms & pseudomonal species are also causes.
How is late onset neonatal infection managed?
Wide variability in this group: likely broad spectrum to cover gram positive + negative (e.g. flucloxacilin + gentamicin). Important to target therapy based on sensitivity data which may vary between populations.
Start Abx if: 1 red flag or 2 risk factors or clinical indicators
NICE: IV benzypenicillin + IV gentamicin recommended (many centres use cefotaxime after local discussion), take blood cultures + CRP at start of Abx, repeat CRP at 18-24 hours.
Abx can be stopped if negative cultures + no rise in CRP 36 hours after first dose. Consider LP if baby very unwell, CRP is >10 or positive culture. Many centres have a higher CRP threshold.
What are the red flags for starting Abx in late onset neonatal infection?
Parenteral antibiotic treatment given to mother for confirmed or suspected invasive bacterial infection at an time during labour or in 24 hour periods before and after birth (does not refer to intrapartum antibiotic prophylaxis)
Suspected or confirmed infection in another baby if multiple pregnancy
Respiratory distress starting >4 hours after birth
Seizures
Need for mechanical ventilation in a term baby
Signs of shock
(Note: if 2 or more non-red flag risk factors, this also indicates Abx, but too many of them to list!)
