Neonatal and newborn Flashcards
Define neonate
Term: Birth until 4 weeks of age
Pre-term: Birth to 44 post menstrual weeks of age
Define pre-term birth
Before 37 weeks
What factors increase the risk of jaundice?
Pre-term babies
Low weight
FHx
Maternal DM
Male baby
East Asian
Generally, what is jaundice within the first 24 hours indicative of?
Haemolysis or sepsis
When does physiological jaundice present?
2 - 3 days of age
Why does physiological jaundice occur?
Immature liver function and increased erythrocyte breakdown; the haemoglobin concentration in neonates is much higher than in adults!
When is jaundice always pathological?
If less than 24 hours after birth
What are the causes of early jaundice?
Haematological: ABO/Rh incompatibility Haemolytic disease of the newborn G6PDD Hereditary spherocytosis Haematoma Maternal autoimmune haemolytic anaemia (SLE)
Infection: TORCH or post-natal infection Toxoplasmosis Other (syphilis, varicella-zoster, parvovirus B19) Rubella Cytomegalovirus (CMV) Herpes
Other: Gilberts syndrome Crigler-Najjar syndrome Dublin-Johnson syndrome Brusing
What is prolonged jaundice?
> 14 days in term
> 21 days in pre-term
What are the causes of prolonged jaundice?
Breast milk jaundice - most common cause
Metabolic:
Galactosaemia
Hypothyroidism
Hypopituitarism
Infection
GI/Conjugated hyperbilirubinaemia:
Biliary atresia
Choledocal cyst
Neonatal hepatitis
Give five causes of conjugated hyperbilirubinaemia
Usually due to neonatal liver disease…
GI: Biliary atresia, choledocal cyst, hepatitis
CF
Alpha1 anti-trypsin deficiency
Galactosaemia
Aminoaciduria
Hypothyroidism
Infection
Parenteral nutrition
In cases of jaundice, what other signs should you look for on examination?
Neurological: Tone, seizures, altered crying (kernicterus)
Haemolysis/infection: Hepatosplenomegaly, petechiae, microcephaly
Pale stools/dark urine
How should you measure bilirubin?
Transcutaneous bilirubinometer if > 35 weeks and >24 hours of age, otherwise serum bilirubin
Give three examples of haemolytic tests used for jaundice
Reticulocyte count
Direct Coombs test: looking for ABO/Rh haemolysis
Haemoglobin and haematocrit
Peripheral blood film for erythrocyte morphology
Red cell enzyme assays: GP6DD, pyruvate kinase deficiency
What investigations should you do in cases of prolonged jaundice?
Look for pale stools and dark urine
Measure the conjugated bilirubin
FBC
Determine blood group and Coombs test
Urine culture
Routine metabolic screening (incl. for congenital hypothyroidism)
What should you start if bilirubin is rapidly increasing or < 24 hours?
Phototherapy
What does phototherapy do?
Converts bilirubin to bilverdin
What are the side effects of phototherapy?
Dehydration and loose stools
What treatments are there for unconjugated hyperbilirubinaemia?
Phototherapy and exchange transfusion
What is kernicterus?
Bilirubin encephalopathy: unconjugated bilirubin enters the brain and causes neuronal damage to basal ganglia
What are the clinical features of kernicterus?
Irritability
High-pitched cry
What is biliary atresia?
Absence of intra/extra-hepatic bile ducts
How does biliary atresia present?
Deelops over a few weeks; stools become clay-coloured
What are the complications of biliary atresia?
Liver failure - transplant
What procedure can be done to correct biliary atresia?
When is it done?
Kasai procedure: hepatopoto-enterostomy
If detected within the first 6 weeks - unconjugated AND conjugated levels must be checked after 2 weeks to check for biliary atresia!
Give three causes of jaundice in older children?
Hepatitis A and autoimmune hepatitis
G6PDD
Reye’s syndrome
Paracetamol overdose
Wilson’s disease
Crigler-Najjar disease
Gilbert’s syndrome
What is Reye’s syndrome and what causes it?
Metabolic condition causing encephalitis and liver failure
Caused by aspirin, which is contraindicated in kids
Severe birth asphyxia can lead to what?
Hypoxic ischaemic encephalopathy
How do foetuses cope with hypoxia?
Quite well actually
Cause they’ve got a high Hb (18g/dL) and a high cardiac output
What factors indicate a diagnosis of birth asphyxia?
pH < 7.05
APGAR 0 - 5 at 10 mins
Delay in spontaneous respiration (> 10 mins)
HIE (abnormal neuro signs, including convulsion for more than 2 days)
How is birth asphyxia managed?
What is important to avoid?
Rapid resuscitation (avoid cerebral oedema)
Treat convulsions
Controlled therapeutic cooling
What does APGAR stand for?
Activity (muscle tone) Pulse Grimace (reflex irritability) Appearance (skin colour) Respiration
What is HIE?
Hypoxic ischaemic encephalopathy is abnormal neurological signs, including convulsion for more than 2 days, following birth asphyxia
What are the differences between mild, moderate and severe HIE?
Mild: irritable, high-pitched cry, poor feeding
Moderate: lethargic, hypotonic, fits
Severe: diminished consciousness, no movement, multiple seizures, organ failure
What are the complications of HIE?
Cerebral palsy
Organ failure
Death
Give three examples of birth marks
Pigmented naevi Cafe au lait spots Strawberry naevus/superficial haemangioma Naevus flammeus (salmon patch) Mongolian blue spots Port wine stain
When do pigmented naevi present?
About 2 years of age
They very rarely present at birth
In what condition are cafe au lait spots a sign?
Neurofibromatosis
What are stork marks?
Naevus flammeus/salmon patches
Where do you get salmon pathches?
Eyelids neck and forehead
Which type of birth lesion do you get in 75% of black and asian people?
Mongolian spots
What are port-wine stains?
Mature, dilated dermal capillaires present at birth.
They are macular and appear sharply circumscribed and pink/purple, in different sizes
What should you suspect if port wine stains are localised to the trigeminal area?
Sturge-Weber syndrome
There is underlying haemangioma and intracranial calcification, causing seizures
What is cephaloheamatoma?
Where does it occur?
Subperiosteal bleeding; it cannot cross the midline.
The swelling and amount of blood loss is limited by the periostem attached to the skull margins.
Cephalohaematoma can make what worse?
Jaundice
Infection of broken skin
What are the risk factors for cephalohaematoma?
Forceps delivery
Large baby
First pregnancy
Difficult/prolonged labour
How does haemolytic disease of the newborn happen?
Maternal IgG crosses the placenta and reacts with foetal RBC antigens
When the foetus is Rh+ and the mother is Rh-, the mother will make anti-Rh antibodies
In the 2nd pregnancy, antibodies cross the placenta to destroy foetal RBCs
What is the test used to check for haemolytic disease of the newborn?
Indirect Coomb’s test - looks for presence of antibodies at first antental visit if mother is Rh-
How can babies with HDN appear clinically?
Jaundice
Pallor
Hepatosplenomegaly
Hydrops fetalis/polyhydramnios
How do you manage HDN in utero?
Transfusion with O negative packed red cells cross matched at 18 weeks into umbilical vein
Deliver at 37-38 weeks; 32 if necessary
How does the management for HDN differ if after delivery?
50% of babies have normal Hb and bilirubin
If moderate disease (25%) then transfusion
If hyperbilirubinaemia - phototherapy to avoid kernicterus
Severe disease - resus, intensive support, transfusion and correction of acidosis
When should mothers be given anti-D immunoglobulin?
28 and 34 weeks, and soon after delivery
How does the gestation at:
- 36 weeks…
- 33 weeks…
- 28 weeks…
…affect neonatal development?
- 36 weeks - slow to feed
- 33 weeks - more serious problem e.g. immature lungs
- 28 weeks - very significant problems
Give three risk factors for prematurity
Young maternal age Multiple [regnancy Infection Maternal illness Cervical incompetence Antepartum haemorrhage Smoking Alcohol
What use are antenatal steroids?
These reduce the incidence of respiratory distress syndrome and intraventricular haemorrhage
How can prematurity affect the…eyes?
Retinopathy due to abnormal vascularisation of the developing retina (increased proliferation with excess oxygen delivery)
Requires laser treatment to prevent retinal detachment and blindness
How can prematurity affect the…respiratory system?
Respiratory distress syndrome (due to surfactant deficiency)
Apnoea
Pneumothorax
Chronic lung disease (needs oxygen after 28 days of age)
How can prematurity affect the…cardiovascular system?
Hypotension
Bradycardia
Patent ductus arteriosus
How can prematurity affect the…temperature control?
Increased SA:volume ratio leads to loss of heat
Immature skin and reduced subcutaneous fat so cannot retain heat and fluid efficiently
How can prematurity affect the…metabolism?
Hypoglycaemia - treat promptly if symptomatic and maintain above 2.6 to prevent neurological damage
Electrolyte imbalance e.g. hypocalcaemia
Osteopenia
How can prematurity affect the…brain?
Intraventricular haemorrhage
Post-haemorrhagic hydrocephalus - needs shunt
Periventricular leucomalacia (often result of hypotension) - increased risk of epilepsy and CP (diplegic type)
How can prematurity affect the…GI system?
Necrotising enterocolitis (life-threatening inflammation of the bowel wall due to ischaemia/infection) - can lead to perforation
GORD
Inguinal hernias (high risk of strangulation)
How can prematurity affect the…blood?
Anaemia of prematurity
Neonatal jaundice
How can prematurity cause infection?
Pneumonia
Sepsis (esp. group B strep and coliforms)
Infection of central venous lines for feeding
How can prematurity affect feeding?
Parenteral nutrition
NG feeds until sucking reflex develops at 32-34 weeks
Difficult to achieve in-utero growth rates
What are the clinical features of NEC?
Abdominal distension (with increasing gastric aspirates)
Visible intestinal loops (football sign - perforation)
Altered stool pattern
Bloody mucoid stool and bilious vomiting
Decreased bowel sounds
Abdominal erythema
Palpable abdominal mass or ascites
Associated features of bradycardia, lethargy, shock, apnoea, respiratory distress, temperature instability.
When does NEC occur?
First two weeks of life (3 - 10 days)
In which cases do babies require resuscitation?
Prematurity
Fetal distress
Thick meconium staining of liquor
Emergency Caesarian section
Instrumental delivery
Known congenital delivery
Multiple births
How do different Apgar scores affect prognosis?
7 - 10 at 1 minute: normal
4 - 6: moderately ill
0 - 3: severely compromised, needs urgent resuscitation
What is done to re-establish cardiac output in neonates requiring resuscitation?
Cardiac massage
IV adrenaline
Bicarbonate
What are the signs of severe asphyxia?
Cord blood pH < 7.0
Apgar < 5 at 10 mins
Delay in spontaneous respiration beyond 10 minutes
Development of HIE (with abnormal neurological signs, including convulsions)
Following moderate to severe asphyxia, what can be done to prevent secondary neuronal damage?
Therapeutic hypothermia (cooling to 33 degrees) for 72 hours
What is the difference between symmetrical and asymmetrical growth restriction?
Asymmetrical IUGR is more common (70%). In asymmetrical IUGR, there is restriction of weight followed by length. The head continues to grow at normal or near-normal rates (head sparing) due to selective shunting to the brain.
Symmetrical IUGR is less common (20-25%). It is commonly known as global growth restriction, and indicates that the foetus has developed slowly throughout the duration of the pregnancy and was thus affected from a very early stage.
What are the causes of asymmetric and symmetric IUGR?
Asymmetric: Placental insufficiency Chronic high blood pressure Severe malnutrition Ehlers–Danlos syndrome
Symmetric:
Early intrauterine infections, such as TORCH
Chromosomal abnormalities
Anaemia
Maternal substance abuse (e.g. foetal alcohol syndrome)
What are babies with IUGR at risk of in the first few days of life?
Hypoglycaemia
Hypothermia
Later: Cognitive impairment (poor head growth)
What is Vitamin K deficiency bleeding?
Deficiency of Vitamin K or persistent obstructive jaundice, leading to poor synthesis of Vitamin K-dependent clotting factors and therefore bleeding.
Can present as minor bruising or significant intracranial haemorrhage
Why and how are Vitamin K supplements given to newborns?
Not enough in breast milk
Given either as a single IM injection or orally, at birth, 1 week and 6 weeks.
What drugs should be given to the mother of a premature baby antenatally?
2 doses of betamethasone 12 mg given intramuscularly 24 hours apart
or
4 doses of dexamethasone 6 mg given
intramuscularly 12 hours apart.
What is the postnatal management of premature babies?
Paediatrician at birth Delay cord clamping after 1 minute Keep warm NIV (5:20) ET tube and surfactant if 27 weeks or less SCBU Breastfeeding/NG/IV feeds Benzylpenicillin/gentamicin if septic
What is respiratory distress syndrome also known as?
Hyaline membrane disease
What is RDS caused by?
Surfactant deficiency
What produces surfactant?
Type II alveolar cells
Why is RDS self-limiting?
The adrenal glands produce endogenous corticosteroids as a response to RDS, which means the condition usually resolves within 7 days.
How can RDS be prevented?
Antenatal administration of corticostroids between 24 and 34 weeks gestation:
2 doses of betamethasone 12 mg given intramuscularly 24 hours apart
or
4 doses of dexamethasone 6 mg given
intramuscularly 12 hours apart.
Give 5 risk factors for RDS
Premature delivery Male infants Infants delivered via caesarean section without maternal labour Hypothermia Perinatal asphyxia Maternal diabetes Family history of IRDS
What are the clinical features of RDS?
Tachypnoea
Intercostal, subcostal and sternal recession
Cyanosis
Expiratory grunting
How does RDS appear on CXR?
Air bronchiogram - radiolucent air in bronchi against airless lung
Bell-shaped thorax
Ground glass appearance of lung fields - due to alveolar collapse
How are neonates with RDS managed?
Oxygen
CPAP - if spontaneously breathing
IPPV - if unable to breathe, need to be intubated
Exogenous surfactant via ET tube
What is a diagnosis of ‘small for gestational age’ (SGA) based on?
An abdominal circumference or estimated foetal weight which is < 10th centile
How far apart should measurements be taken?
At least 3 weeks apart
If a newborn is < 10th centile or has reduced growth velocity, what should they be offered?
Serial assessment of foetal size
Umbilical artery doppler scan
Give five major risk factors for SGA
Maternal age >40 years. Smoker - ≥11 cigarettes per day. Paternal or maternal SGA. Cocaine use. Daily vigorous exercise. Previous SGA baby. Previous stillbirth. Chronic hypertension. Diabetes with vascular disease. Renal impairment. Antiphospholipid syndrome. Heavy bleeding similar to menses. Pregnancy associated plasm protein-A (PAPP-A) <0.4 multiples of the median (MOM).
Under what circumstances are mothers reassessed for present SGA risk factors?
What do they look for?
If one major risk factor or > 3 minor risk factors, women are reassessed at 20 weeks for abnormal Down’s markers and fetal echogenic bowel
What are the criteria for uterine artery doppler scans?
Elevated ratio of FL:AC
Elevated ratio of HC:AC
Oligohydramnios
What other investigations to suspected IUGR babies undergo?
TORCH screening
Karyotyping
How does the timing of delivery differ in SGA foetuses with absent or reversed end-diastolic velocity (AREDV) < 32 weeks?
Deliver by C-section when ductus venosus doppler becomes abnormal or umbilical vein pulsations appear, provided the foetus is viable and completion of steroids
How does the timing of delivery differ in SGA fetuses with a normal doppler before 32 weeks?
If doppler is normal, delivery is recommended by 32 weeks
Can off induction of labour, but emergency CS rates are increased
When should a baby be delivered if the middle cerebral doppler scan is abnormal?
No later than 37 weeks
When should a baby be delivered if detected as SGA after 32 weeks, with an abnormal UAD?
No later than 37 weeks
How can SGA birth be prevented in women with a high risk of pre-eclampsia?
Anti-platelets at 16 weeks
Why does talipes occur?
Fetal foot position in utero
Tight Achilles tendon
What other conditions can talipes be associated with?
Cerebral palsy
Spina bifida
Arthrogryposis
How are talipes diagnosed and graded?
Antental US
Graded by the Pirani score (0 - 6)
What are the different types of club foot?
Talipes equinovalgus
Talipes equinovarus
Talipes calcaneovalgus
Talipes calcaneocavus
How are talipes treated?
Ponseti technique - stretching and manipulation, before setting in plaster cast
Takes up to 10 weeks to work and must wear special boots afterwards to prevent recurrence
Surgery
How often is serum bilirubin checked during phototherapy?
When is treatment stopped?
Check very 8 - 10 hours
Stop phototherapy when the value is 50 under the treatment line
Clinically, how does GORD differ from just GOR?
Irritability
Back arching
