Neonatal medicine Flashcards
What are the signs of respiratory distress in a neonatal?
Intercostal recession
Subcostal recession
Nasal flaring
Tracheal tug
Head bobbing
Grunting
- trying to drive air into the lung
What is the management of respiratory distress in a neonatal?
Oxygen
CPAP
Artificial surfactant
Antenatal steroids
What are the signs and symptoms of intraventricular haemorrhage in a neonate, and how is it diagnosed?
Common in preterm or low birth weight.
- Ultrasound used to diagnose
- MRI may be used for more detailed imaging.
- 4 grades, with grades 1 and 2 have favourable outcomes, grade3,4 having long term sequalae
Seizures
Apnoea’s
Bulging fontanelle
Cerebral irritability
What is the area within the ventricles that bleeds in a intraventricular haemorrhage.
Germinal matrix
Why are premature infants at risk of infection?
Lack maternal IgG reserves Multiple lines in situ Hospitalisation for long periods Thin skin Lack of physiological reserve - hypoglycaemia, hypothermia
What are some signs of sepsis that are specifically seen in neonates?
Poor feeding
Lethargy/ constant sleeping/ difficult to maintain awake
Jaundice
Seizures
Crying
- persistent
- high pitched (cerebral irritation)
Fever/ hypothermia (more common in pre-term)
Fontella shrunken/ bulging
What is the antibiotic management in neonates with sepsis?
<72 hours old:
- IV penicillin + IV Gent
+
Aciclovir
> 72 hours old:
- IV Flucloxacillin + IV gent
+
Aciclovir
*based on the likely pathogens
Why are neonates more susceptible to jaundice?
Shorter life span RBCs
Lower levels of liver enzyme activity
- glucosyl transferase
Slower intestinal tract transit
- allow more reabsorption
Medications displacing albumin from bilirubin
Breast milk can lead to unconjugated jaundice
What are some of the causes of jaundice in neonates?
Conjugated:
- biliary atresia
- Cystic fibrosis
- hepatitis
- TPN
Early unconjugated:
- sepsis
- Rh incompatibility
- ABO incompatibility
- Haemoglobinopathies
> 24 hours:
- physiological
- breast milk
> 2 weeks:
- biliary atresia
- breast milk
- congenital hypothyroidism
What is the major complication of neonatal jaundice? and how does it present?
Kernicterus: bilirubin binds irreversibly to the neuroreceptors of the basal ganglia
early features:
- poor feeding
- lethargy
Late finding:
- hypertonia
- seizures
- coma
Complications:
- death
- deafness
- cerebral palsy
- intellectual defects
- athetoid movements
What is the management of a jaundice baby?
Conservative
- monitor bilirubin levels
- maintain hydration
Phototherapy
Exchange transfusion
*all guided by the threshold chart
What is the surgery used in biliary atresia?
Kasia Porto- enterotomy
or
Liver transplant
*give vitamin K
How should CPR be delivered in a neonatal/ child? and what is the heart rate at which you would start chest compression at?
- Immediately 5 rescue breaths
(if baby cover both mouth and nose with your mouth) - Neonate: 3:1
- Child: 15: 2
Chest compression for a neonate should be started at: <60bpm
*rate 100-120bpm
What is a complication that occur during birth that can lead to a swollen head of a child taking several months to resolve? and what is it typically associatted with?
Cephalohematoma
- bleeding between the periosteum and skull
- usually on parietal region
Can be associated with forceps delivery.
What is a common cause of seizure within the first 72 hours after birth?
Bleeding witihin the ventricular system causing hydrocephalus
What are the red flags for constipation in a child?
Present from birth
Delayed passage of meconium >48 hours
Ribbon stools
Neurological symptoms
Abdominal distension
What is the average weight of a baby at term?
3.5kg
In an adolescent history, what key things do you want to ask?
HEADS
Home Environment/ employment Activities Drugs Sexual health/ Suicidal thought
What is the most common cardiovascular defect in Down’s Syndrome?
Atrioventricular septal defect
2nd is ventricular septal defect
What features may you see on physical examination of a newborn with Down’s Syndrome?
Generalised Hypotonia
Epicanthal folds
Upslating palpebral fissures
Brachycephaly
Excess skin on neck
Singel palmer crease
Sandal toe gap in feet
Short stature/ poor growth
List 5 neurological complications of Down’s syndrome:
Learning difficulties
Hearing impairment
- Neurosensory
Strabismus
- exotropia
- exotropia
Increased incidence of epilepsy
Atlantoaxial instability
*Alzheimer’s risk in lalter life (3 copies of APP)
List some of the features seen in a baby with Edwards syndrome:
Trisomy 18 - Edwards:
Microcephaly and small chin
Low set ears
Overlapping fingers in a clenched fist
Rocker Bottom feet
Cardiac:
- VSD
- ASD
- PDA
**90% don’t survive past 1 year
What are the features seen in Patau syndrome/ Trisomy 13?
Microcephaly
Small eyes
Renal abnormaliteis
- horse shoe
Polydactyly
Name some symptoms and clinical signs of pyloric stenosis:
Effortless projectile vomiting following feeds
- no bile
Peristaltic waves in upper quadrant of stomach
Mass in epigastrium
- right upper quadrant
Hypokalemia
Metabolic alkalosis
What Is the definitive diagnostic investigation and definitive management of pyloric stenosis?
Ultrasound
Ramstedt’s pyloromyotomy
What are some signs and symptoms of bowel intussusception?
Symptoms:
- Paroxysmal abdominal colic pain
- Turns pale when bringing knees up
Signs:
Sausage sized mass in RUQ
Empty RLQ
- Dance sign
Redcurrant jelly discharge
Pallor patient
What is the pathology that can arise with oedema on the head due to pressure passing through the birth canal?
Caput Succedaneum
- oedema: passing the suture lines
*disspears within days
What is the resuscitation protocol of a neonate?
- Dry and warm baby >26 degrees.
- Calculate APGAR
- neuro, HR, Breathes per min - Simulate breathing
- neutral position
- rubbing - Inflation breaths
- 2 x 5 inflation breaths - 30 secs each
- ventilation +/- oxygen (if preterm) - Chest compression
- 3:1
What are some of the pros of breast feeding to the mother and baby?
Mother:
- reduced breast cancer
- reduced ovarian cancer
- reduced diabetes
- potentially reduced postnatal depression
- reduce risk of PPH
Baby: Receives IgA and macrophages from mother which reduces a host of infections such as: - Reduced gut infection - reduced respiratory infection - reduced ear infection
Reduces risk of:
cardiovascular disease
autoimmune conditions
sudden infant death syndrome
increases
- improved cognitive ability
- mother - baby bonding
Why are babies at risk of malnutrition?
High growth rates Low reserves of store Small size - high metabolic rate High levels of activity Increased rates of infection Dependence on other for food
List some causes of jaundice in the first 24 hours of life:
Rhesus Haemolytic disease of the new born
- reduced due to anti-D prophylaxis
ABO incompatibility
- weak immunological response so not as devastating as Rh disease
G6PD
Sepsis
List some causes of prolonged jaundice (>14 days)
Biliary atresia
Hypothyroidism
UTI
Breast milk
Congenital infections
- toxoplasmosis
What are the key features seen in Hirschsprung disease?
Failure to pass meconium in first 48 hours
Abdominal distension
Bilious vomiting
Explosive foul smelling faecal matter if digital rectal examination
*can become hirsprung related enterocolitis
What are some signs indicative of hypoxic ischemic injury?
Poor cord gases
Irritability
Absent suckle reflex
Seizures
What are some risk factors for neonatal sepsis and what are the most common organisms?
Maternal fever
Prolonged rupture of membranes
Prematurity
Low birth weight
- group B strep
- E. Coli
What are the head injuries caused by forceps?
Cephalohematoma
- outwith the skull so will not cause raised ICP
Caput succedaneum
Subgaleal haematoma (due to rupture of the emissary veins) - this can be serious as it is below the galeal aponeauosis but above the suture lines to can enter into the cranium causing wide spread bleeding within the cranium
What is the time peroid for neonatal death?
within the first 28 days of life
Brachial plexus injuries can occur and are more common with breech deliveries. Name two types of brachial plexus injury and their nerve root injury and appearance:
Erb’s palsy:
- C5-C6
- weak arm flexion and supination
- extended arm and pronated in
Klumpske’s palsy:
- C8-T1
- weakness of extensors and intrinsic finger muscles
- flexed arm and weak hand.
- associated with Horner’s syndrome
List some differentials for bilious vomit:
Duodenal Atresia
- double bubble sign
- contrast study for diagnosis
Jejenal/ ileal atresia
- AXR with airfluid levels
Meconium ileus
- AXR
- check for CF
Necrotising enterocolitis
- Dilated abdomen
- Pneumoatosis
Why is the pharmacokinetics in babies different to adults?
reduced pH of the stomach
Reduced bile secretion
Reduced intestinal mobility
High percentage of water
- increasing water solubility
Immature liver enzymes
Reduced bioavailability
What is the most important aspect of pharmacokinetics in neonates?
Excretion
- increasing the half life
What is Hutchison’s triad?
Set of symptoms relating to congenital syphilis, consisting of:
- hearing loss
- Mouth and nose deformities (saddle nose)
- eye pathologies (glaucoma, corneal clouding)
List some signs and symptoms associated with congenital rubella:
Congenital heart disease
- PDA
Blueberry muffin rash
Cataracts
Neurosensory hearing loss
Meningocephalitis
Which TORCH infections cause calcification in the brain and what are the difference between the two?
Toxoplasmosis:
- diffuse intracranial calcification
CMV:
- Periventricular calcification
List some risk factors for neonatal sepsis:
GBS in the mother Early placental rupture Prolonged labour Preterm Small for gestational age
List some causes of unconjugated hyperbilirubinemia and list the main cause of conjugated and describe how it presents:
Unconjugated:
- Physiological
- breast milk
- Haemolytic disease
- Infection
- Congenital hypothyroidism
Conjugated:
- biliary atresia
- presents with pale stools and dark urine plus jaundice
- TORCH infections
- Hepatitis
What two things determine the treatment for newborn jaundice and what is the complication of jaundice:
Gestational age and bilirubin level
Kernicterus
What is prolonged jaundice of the neonate and what investigations should it trigger?
> 14 days
21days in preterms
should think about:
- biliary atresia
- hypothyroidism
- Haemoglobinopathies (G6PD)
- Neonatal hepatitis
*breast milk is the most common cause of prolonged jaundice.
Define neonatal sepsis:
Sepsis that occurs in the first 28 days.
- Early onset neonatal sepsis being <48 hours
- Late onset neonatal sepsis being >48 hours
What antibiotics are given in neonatal sepsis?
Early onset: - IV Benzylpenicillin \+ - IV Gentamicin \+/- Aciclovir
Late onset: - IV flucloxacillin \+ - IV Gentamicin \+/- Aciclovir
