Neonatal Flashcards
What is the difference between cephalhaematoma and caput succedaneum?
- Both are non-concerning injuries causes by birthing trauma (instruments)
- Caput succedaneum is associated with venous delivery and it extends across suture lines (like a cap). It is self-limiting (few days)
- Cephalhaematoma is a subperiosteal bleed limited by suture lines (one side. Self limiting (couple of weeks-longer because bound by periosteum)
What is an example of a pathological, concerning head trauma associated with birthing injury?
If the birth is particularly traumatic it can cause Intraventricular haemorrhage (IVH):
- Bleeding into the ventricles of the brain - as blood pools here it can clot and cause blockage to the drainage of CSF.
- This can lead to hydrocephalus
What is the most common nerve palsy associated with traumatic delivery? Describe it and suggest management.
ERB’S PALSY - damage to C5, C6 nerve roots - associated with shoulder dystocia
- The arm is flaccid, the forearm is pronated and the wrist flexed - WAITER’S TIP
- Prognosis depends on damage (physio may resolve or may be there for life)
- Important to get an x-ray of the clavicle to exclude fractures
What other nerve palsies can occur with traumatic delivery?
FACIAL NERVE PALSY - following pressure on the face from maternal ischial spines or forcept
- FACIAL ASYMMETRY worse on crying
- Majority will recovery within a week or 2 but they might need some ophthalmological input
What are some of the most common fractures for baby’s to get during a traumatic delivery and how should they be managed?
CLAVICLE - not uncommon with big babies, they need to be immobilised - have their arm inside their baby grow and usually have healed in a few weeks
AVULSION FRACTURES of the humeral or femoral epiphysis is also not uncommon
SKULL FRACTURES - slight risk with forceps - consider neuro r/v
What is the most common cause of birth asphyxia?
Drop in maternal blood flow during delivery
- Excessive haemorrhage
What sorts of problems might birth asphyxia cause?
Developmental delay
Intellectual delay
Physical problems e.g. spasticity - CEREBRAL PALSY
RISK OF HYPOXIC ISCHAEMIC ENCEPHALOPATHY (HIE)
What are some risk factors for birth asphyxia?
Elderly or young mothers Prolonged rupture of membranes Meconium stained fluid Multiple births Lack of antenatal care Low birth weight Malpresentation Use of oxytocin augmentation in labour APH Pre-eclampsia and eclampsia Anaemia
What causes HIE?
PERI-NATAL ASPHYXIA either due to poor pulmonary gas exchange in the newborn or poor placental perfusion in the mother
This leads to decreased cardio-respiratory effort> hypoxia> hypercapnia> metabolic acidosis>hypo perfusion>end organ ischaemia in the brain - HIE
What are the affects of HIE and what can we do to counter these?
- Neurodisability as well as death in the infant
- Immediate (primary) neuronal death from the hypoxic injury or further death of these tissues might occur when due to re-perfusion injury
- We can try and protect/delay this secondary injury with THERAPEUTIC COOLING to induce hypothermia
What are some SPECIFIC causes of HIE?
What are some of the causes?
- Failure of gaseous exchange across the placenta
○ Placental abruption
○ Ruptured uterus
- Interruption of umbilical blood flow
○ Excessive or prolonged uterine contractions
○ Cord compression
○ Cord prolapse
○ Shoulder dystocia
- Inadequate maternal placental perfusion
○ Maternal hypotension or hypertension
○ This is often associated with intrauterine growth restriction
- Compromised fetus
○ Anemia
○ IUGR (intra uterine growth restriction)
○ Failure to breath at birth
- CAN BE CAUSES BY NEONATAL CONDITION
○ Inborn error of metabolism
Kernicterus
When and how will we know HIE has occurred (features)?
1. Mild: ○ Responding excessively to stimulation ○ Staring of the eyes ○ Irritable ○ Hyperventilation ○ Impaired feeding
2. Moderate: ○ Marked abnormalities of tone and movement ○ Cannot feed ○ May have seizures 3. Severe: ○ No normal spontaneous movements or responses to pain ○ Tone in the limbs may fluctuate between hypertonia and hypotonia ○ Seizures are prolonged and often not responsive to treatment ○Multi-organ failure is often present
How should we manage HIE?
- Resuscitation and stabilisation
- COOLING (32 degrees for 72 hours)
- Respiratory support
- EEG monitoring -identify seizures and encephalopathy
- Treat seizures if they have
- Fluid restriction because of renal impairment, prevent odema (40ml a day)
- Moniter and treat electrolyte inbalance
What is the prognosis for babies with HIE?
- Complete recovery can be expected if babies have MILD HIE
- In some moderate cases there will be partial recovery in the first 2 weeks (although there is not likely to be any recovery after this time)
- PERFORM MRI at day 4 and day 14 - if significant abnormalities exist bilaterally in the basal ganglia, thalamus and internal capsule (lack of myelin) then this is a strong predator of CEREBRAL PALSY
When should APGAR scoring be done?
1, 5 and 10 minutes
What are the categories in APGAR scoring and how are they scored?
Activity/Muscle tone
- none=0
- flexed arms and legs=1
- active =2
Pulse
-absent=0
<100bpm=1
>100bpm=2
Grimace/Reflex irritability to stimuli
No response=0
Minimal response to stimuli=1
prompt response to stimuli=2
Appearance/Colour
Blue/pale=0
Pink centrally but with slightly blue peripheries =1
pink all over =2
Respiration
none=0
infrequent and irregular =1
normal (vigourous cry)=2
What is a normal APGAR score?
An ideally healthy baby should score 10, however scores of 7+ are normal
-Very often even health babies have slightly blue extremities, this loses them a point on appearance but is not often a cause for concern.
What is necrotising entircolitis (NEC)?
When and who does NEC usually occur?
- Gut gets inflamed and starts to die
- In premature babies and it will often develop in the first few weeks of life. More common in cows milk fed babies
What are some features of NEC?
Stopping tolerating feeds Aspiration Vomit +/- bile stained Abdominal distension Fresh blood in the stool SHOCKED - due to distension and pain
How should we investigate NEC?
AXR
- Will see distended loops of bowel
- Thickening of the bowel wall due to intra-mural gas
- Gas in the portal tract
How should we treat NEC?
Stop oral feeding (TPN) Broad spectrum abx (aerobic and anaerobic bacteria) Ventilatory support Cardiovascular support Danger of BOWEL PERF - refer to surgery
What can be offered antenatally to help prevent NEC?
Erythromycin
What is the prognosis in infants with NEC? Long-term complications?
-Mortality rate is about 20% LONG TERM SEQUELAE: -Strictures -Malabsorption -Short bowel syndrome as consequence of surgery
What is the first thing you should do when resuscitating a newborn?
DRY THE BABY
Then assess breathing, heart rate and tone
Newborn resuscitation: After drying it what is the next stage in neonatal resuscitation?
- Optimise airway (face parallel to surface)
- Assess tone, resp and heart rate
- ADMINISTER 5 RESCUE BREATHS
- Repeat this, improving manoeuvres and considering intubation until the chest is seen to rise
Newborn resuscitation: Spontaneous ventilation has recovered what is the next stage in neonatal resuscitation?
- Assess for heart beat and if there is none, or it is low (<60bpm) begin chest compression with compression:breath ratio of 3:1
- Re-assess for heart beat every 30 seconds until heart rate is >60bpm
What would you expect of the saturations of a neonate?
THEY ARE VERY OFTEN VERY LOW and this is not always concerning - check them to see whether they recover
Neonates also very often have something called
TRANSIENT TACHYPNOEA OF THE NEWBORN (TTN) where grunting or occasional nasal flaring might occur
- monitor reps rate and sats and respond accordingly
What % of babies are jaundiced and is this always concerning?
60% babies jaundiced - very often this is physiological
Should you be concerned about jaundice in the first 24h of life??
YES - jaundice in the first 24h of life is ALWAYS PATHOLOGICAL
Describe why physiological jaundice occurs?
When babies are born they have
- high levels of RBC
- high turnover rate
- low liver maturity so cant congegate (build up of uncongegated bilirubin that cannot be excreted)
When will physiological jaundice occur? and when will it go?
Physiological jaundice will happen in the first 2-3 days of life and it should disappear after 10 days as the liver matures
What should we do if a baby (older than 24 hours) has jaundice?
Reassure parents
- very common and harmless
- self limiting should go away after ten days
- more common in pre term and breast fed babies
Investigations
-look at bilirubin levels (bilirubinometer) to to see whether it reaches the threshold for treatment (use a bilirubin threshold graph specifically for gestational age)
-DIrect antiglobin Coombs test
-FBC and blood film TFT LFT Us&Es
-Urine dipstick (glucose and infection-do a culture)
particularly common in breast-fed babies (might be slightly dehydrated)
What are some causes of early jaundice/heamolytic disease of newborn
Causes of early jaundice
-Sepsis
-ABO incompatibility and Rh disease (heamolytic anaemia)
-Polycythemia (IDM)
-RBC deformities (G6DP (mainly males)/Hereditary spherocytosis)
-Cephalohematoma
SHOULD INVESTIGATE FOR ALL OF THESE
When do we deem it prolonged jaundice?
- Once it has lasted for longer than 2 weeks (14 days)
- OR longer than 3 weeks (21 days) in a pre-term baby
What are some causes of prolonged jaundice?
- Biliary atresia (increased congegated-surgical emergency)
- Breast-milk jaundice (should investigate for liver disease extensively before just calling it this)
- Breast milk failure
- G6PD deficiency
- Gilberts disease (reduced production of liver enzymes)
- Crigler-najjar syndrome
- Galactosemia
- Congenital hypothyroidism
If you do some blood tests and find the bilirubin to be conjugated what does this mean?
This suggests that the cause is LIVER DISEASE (either biliary atresia (surgical emergency) or neonatal hepatitis)
- OBSTRUCTIVE JAUNDICE (pale stools and dark urine)
What tests/investigations should we consider in early jaundice within 24 hours?
Sepsis or heamolysis until proven otherwise
• SEPTIC SCREEN
- Blood cultures
- Urine cultures
- CSF-lumbar puncture
• Screen for HEAMOLTYIC ANEMIA
- Maternal group and antibodies
- Group and Coombs test (direct) -if clumping its positive for rhesus
- FBC (heamatocrit may show heamolysis. Also sepsis)
- Blood film (Bite and blister cells in G6PD/Spherocytes in hereditory spherocytosis
