Neonatal medicine Flashcards by John Darlington

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

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What is the management of respiratory distress in a neonatal?

Oxygen
CPAP
Artificial surfactant
Antenatal steroids

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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

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What is the area within the ventricles that bleeds in a intraventricular haemorrhage.

Germinal matrix

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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

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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

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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

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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

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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

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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

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What is the management of a jaundice baby?

Conservative

monitor bilirubin levels
maintain hydration

Phototherapy

Exchange transfusion

*all guided by the threshold chart

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What is the surgery used in biliary atresia?

Kasia Porto- enterotomy
or
Liver transplant

*give vitamin K

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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

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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.

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What is a common cause of seizure within the first 72 hours after birth?

Bleeding witihin the ventricular system causing hydrocephalus

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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

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What is the average weight of a baby at term?

3.5kg

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In an adolescent history, what key things do you want to ask?

HEADS

Home
Environment/ employment 
Activities 
Drugs 
Sexual health/ Suicidal thought

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What is the most common cardiovascular defect in Down’s Syndrome?

Atrioventricular septal defect

2nd is ventricular septal defect

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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

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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:

**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?

1. Dry and warm baby >26 degrees. 2. Calculate APGAR - neuro, HR, Breathes per min 3. Simulate breathing - neutral position - rubbing 4. Inflation breaths - 2 x 5 inflation breaths - 30 secs each - ventilation +/- oxygen (if preterm) 5. 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 Malrotation with volvus - 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 ```