neonatal medicine Flashcards
Cause of HIE
Caused by reduced cardiac output essentially Failure of gas exchange across placenta: rupture, abruption, prolonged contractions interuption of umbilical blood flow: cord compression, shoulder dystocia compromised foetus: anaemia, IUGR failure of cardio-resp adaptation: don't start breathing
What are three clinical grades of HIE
mild:
irritable and excessive response to stimuli
increased reflexes
may be staring
Moderate: slight abnormalities of tone and posture increased reflexes NOT FEEDING may have seizures
severe:
no reflexes, unresponsive to pain
no tone or movement
Mx of HIE
mild: resuscitate (ABC) therapeutic hypothermia ventilate cardiovascular support (consider inotropes) fluids
moderate: same as above tx seizures normoglycaemia GIVE VIT K monitor liver withhold feeding for 48 hours (at increased risk of NEC)H
severe:
as above +
cranial US to exclude other causes of haemorrhage
MRI brain
What are some injuries during birth
extracranial haemorrhage
caput succadeneum - bruising + oedema of presenting part BEYOND margins of skull bones
cephalhaematoma - haematoma below periosteum (confined to sutures)
Nerve palsies from breech birth
humerus+ clavicle fractures from breech birth
Signs of RDS
see at birth or within 4 hours Tachypnoea (>60) subcostal recession w/ nasal flaring grunting cyanosis if severe
Mx RDS
ABC resus
resp support:
headbox/nasal cannulae
OR nasal continuous positive airway pressure OR positive pressure ventilation if baby doesn’t meet any of those criteria
Fluids
IV Abx (BSA)
URGENT CXR
How does pneumothorax happen
in ventilated RDS babies air leaks into pleural cavity
Mx pneumothorax
Small - observation + 100% o2
needle drainaige if urgent
chest drain - for all tension pneumothorax
what are causes of pneumothorax in term babies
Secondary to:
meconium aspiration
RDS
ventilation
Why are neonates prone to hypothermia
Thin skin
high SA:vol
no subcutaneous fat
often naked
What are the signs of PDA
it causes apnoea, bradycardia, increaed o2 requirements
can see bounding pulse, precordial impulse, systolic murmur
mx of PDA
Close duct using IV indomethacin or surgery (ligation or percutaneous catheter closure)
When can infants feed (suck and swallow)
35-36 weeks - before then NG
What are common causes of preterm brain injury
perinatal asphyxia and RDS
What is most severe kind of preterm brain injury
unilateral haemorrhagic infarction involving parenchyma - leaves you hemiplegic
What are other complications of preterm brain injury
intraventricular haemorrhage can lead to hydrocephalus
Ventricular involvement = 50% chance of neurodevelopmental problems
What is perventricular leukomalacia
multiple bilateral cysts on US (these cysts develop 2-4 weeks after injury)
high risk of spastic diplegia (stiff CP)
what is NEC
bacterial infection of ischaemic bowel wall
signs of NEC
infant can’t feed
distended abdo
bile stained vomiting
may get rectal bleeding
X-ray signs of NEC
distended bowel
thickened bowel wall cause of intramural gas (pneumatosis intestinalis)
Mx of NEC
stop feed (need TPN if stop for >24 hours, if confirmed NEC stop for 7 days)
BSA
NG tube and check aspirates
fluids
ventilation
Surgery if: perforation or child doesn’t respond to medicine
What causes retinopathy of prematurity
high o2 conc on NNU
can lead to retinal detachment
What is bronchopulmonary dysplasia
Damage to newborn’s lungs (often happen as a reuslt of ventilation or trauma)
CXR can show opacification
if they get RSV or pertussis they can go into resp failure
What are benign causes of neonatal jaundice
Too many RBC when born so they break down
RBC lifespan is shorter (70 days)
hepatic metabolism is slow
Signs of kernicterus
acute- lethargy and poor feeding
severe - irritability
increased tone and arched back (opisthotonos)
seizures
Causes of acute neonatal jaundice <24 hours
Haemolytic: Rhesus haemolytic disease ABO incompatibility (less severe than Rhd) G6PD spherocytosis
Congenital infection
Causes of neonatal jaundice 2 days - 2 weeks
physiological Breast milk jaundice dehydration infection polycythaemia
Causes of neonatal jaundice >2 weeks
unconjugated: infection breast milk jaundice hypothyroidism physiological
conjugated:
biliary atresia
neonatal hepatitis
Which drugs can cause jaundice
Diazepam and sulfonamides displace bili from albumin so avoid in babies
assessment of neonatal jaundice
measure bili:
if jaundice developed in less than 24 hours or baby is less than 35 weeks do serum bili
if not do transcutaenously
assess risk of kernicterus:
serum bili >340 in >37 weeks
bili rising >8.5 per hour
clinical signs
Ix for underlying cause: haematocrit blood group DAT test consider G6PD
Tx of neonatal jaundice
Physiological: reassure
use threshold table to see what tx they need
Pathological unconj: acute bili encephalopathy- 1 exchange transfusion 2 phototherapy 3 hydrate 4 IVIg
bili .>95th centile for photo
1 photo
2 hydrate
bili >95th centile for exchange 1 exchange 2 photo 3hydration 4 IVIg
Breast milk jaundie:
temporary cessation of BF
photo+hydration
exchange transfusion
What happens if baby is on borderline for jaundice treatment
If >38 weeks and > 24 hours and within 50micromol of phototherapy threshold repeat bili measurements (within 18 hours if RF present, 24 if not present)
What causes transient tachypnoea of newborn
caused by delay in reabsorption of fluid, most common cause of RDS
mx for transient tachypnoea of newborn
supportive therapy
if tachypnoea goes on for more than 4-6 hours begin Abx
What are the consequences of meconium aspiration
Infection
at increased risk of pneumothorax
increased risk of persistent pulmonary HTN
Mx of meconium aspiration
if meconium staining but no Hx of GBS observe
if infection give Abx (IV ampicillin and gentamicin) and O2
What is persistent pulmonary HTN associated with
RDS
Asphyxia
meconium aspiration
septicaemia
mx of persistent pulmonary HTN
urgent echo to check for congenital defects oxygen ventilate surfactant suction secretions fluids and inotropes inhaled NO ECMO
How does diaphragmatic hernia presetn
generally L sided herniation so:
absent breath sounds on L and apex beat shifted R
mx of diaphragmatic hernia
intubate
positive pressure ventilation
large NG tube + suction to prevent distension of intrathoracic bowel
Then go for surgical repair
Consequence of diaphragmatic hernia
pulmonary hypoplasia due to compression from bowel loops
What are early onset infections (<48 hours)
GBS
listeria
e.coli
Late onset infections (>48 hours) causative organisms
coagulase negative staph (staph epidermidis)
staoh a
klebsiella
pseudomonas
GBS mx
Intrapartum abx (IM benzylpenicillin) if:
previous baby w/ GBS
asymptomatic bacteriuria
infection during current pregnancy
give penicillin and gentamicin to babies
if it’s inc CSF change to benzylpenicillin and gentamicin
Signs of listeria infection
these babies are often preterm
neonatal signs:
meconium staining (rare in preterm)
widespread rash
pneumonia etc.
mx of neonatal listeria
amoxicillin and gentamicin
Causes of conjunctivitis
Bacterial - staph and strep present w/ discharge and redness, gonococcal is purulent + swelling
viral is more relaxed
RF for neonatal hypogylceamia
IUGR Preterm maternal DM Polycythaemia large
Mx of neonatal hypoglycaemia
Prevention - feed baby within 30 mins of birth
aim for glucose >2.6
if BM <1.5 admit and give IV glucose
if BM 1.5-2.5 feed and then reassess in 30 mins
if it’s due to hyperinsulinism give glucagon infusion
features of neonatal seizures
repetitive movements that continue when restrained
accompanied by eye movements and respiration changes
Causes of neonatal seizures
neuro causes (HIE etc.)
metabolic (hypoglycaemia)
kernicterus
withdrawal (maternal opiates)
Mx of cleft lip/palate
feeding assessment
refere to MDT
surgery
at risk of pierre robin sequence
definition of failure to thrive
weight falls below 5th percentile multiple times or crosses 2 percentile lines
Features of oesophageal atresia
Get transoesophageal fistula
associated with polyhydramnios
persent with salivation
Causes of small bowel obstruction
atresia/ stenosis of duodenum (down's) atresia/stenosis of jejunum or ileum volvulus malrotation meconium ileus/plug
Causes of large bowel obstruction
Hirschprung
Rectal atresia
mx chronic lung disease of prematurity
prophylaxis: steroids if established preterm labour <34 weeks
resp support : high flow o2, CPAP, invasive ventilation
medication: dexamethasone if > 8 days, give NO only if pulmonary hypoplasia or pulmonary HTN
Group b strep mx
prevention:
itrapartum benzylpenicillin if: previous you’ve had previous invasive group B strep, group b strep colonisation, bacteriuria or infection in current pregnancy
haemolytic disease of newborn mx
maternal:
anti-D Ig - give at 28 and 34 wks and at birth
baby:
Resusc (A+E)
exchange transfusion if (bili rising >8 per hour despite phototherapy, severe hyperbilirubinaemia unresponsive to phototherapy, significant anaemia <100)
phototherapy
IVIg - only for immune haemolysis
