Neonatal medicine Flashcards
What is hypoxic ischaemic encepalopathy?
Reduced cardiac output / oxygen delivery causing hypoxic-ischaemic injury to brain and other organs
What are causes of HIE?
- Failure of gas exchange across placenta (prolonged contractions, placental abruption)
- interruption of umbilical blood flow (cord compression)
- inadequate maternal placental perfusion
- compromised foetus
- failure of cardioresp adaptation at birth
When do clinical manifestations of HIE start?
Up to 48 h after injury
What is HIE grading like?
Mild
Moderate
Severe
What is mild HIE ?
irritable excessive response to stimulation staring eyes hyperventi,ation impaired feed
What is moderate HIE
marked abnormalities in tone and movement
cannot feed
seizures
severe HIE
no spontaneous movement
no response to pain
seizures
multi organ failure
What is HIE prognosis ?
good if mild / moderate high mortality (40%) if severe + neuro disabilities (cerebral palsy)
What are soft tissue injuries that can occur to the foetus?
caput succedaneum (brusing + oedema of presenting part)
Cephalhaematoma (bleeding below the periosteum, wtihin margins of skill sutures)
Chignon (from ventouse)
Bruising (face/buttock)
What is the most common brachial plexus injury ?
Erb’s palsy (C5, C6)
What is management for brachial plexus palsies
most will resolve completely
What is the most likely cause of a clavicle fracture?
shoulder dystocia
What is skin like in a pre term baby=
very thin
dark red colour
What is genitalia like in a pre term baby?
smooth scrotusm, no testes
prominent clitoris, wide labia major, protruding labia minor
What kind of feeding do pre term babies need
TPN, then tube feeding
What is respiratory distress syndrome
deficiency of surfactant
causes widespread alveolar collapse and inadequate gas exchange
What are RF for RDS?
pre term foetus
maternal diabetes
Whaqt are clincial signs of RDS?
WITHIN 4 H of birth
tachypnoea
laboured breathing with chest wall recession (sternal, subcostal indrawing) and nasal flare
expiratory grunting
cyanosis
How do you manage RDS?
oxygen, ventilation (CPAP/artificial ventilation)
How does pneumothorax present in a newbord?
increased oxyfgen demand
reduced breath sounds
chest expansion
How can you demonstrate newbord pneumothorax?
transillumination
How do you manage newborn pneomothorax
immediate decompression
oxygen therapy
chest drain if tension
What are causes of newborn pneumothorax
spontaneous
meconium aspiration
resp distress syndrome
Why do foetuses have more difficult temp control
large surface area to volume ration
thin skin, heat permeable
little subcut fat
often nursed naked
How does a patent ductus arteriosus present?
apnoea, bradycardia
increased oxygen requirement
difficulty weaning infant off ventilation
bounding pulse
how do you manage patent ductus arteriosus
IV indomethacin
ibuprofen
surgical ligation
How old are babies when they can start sucking and swallowing?
34 weeks
How does feeding occur for infants who cannot suck and swallow?
via orogastric / nasogastric tube
When does breast milk need to be supplemented
In very preterm infants
with phosphate, protein, calciu, calories
What does cows milk increase risk of
Necrotoising enterocolitis
What tool can be used to identify brain haemorrhage in very low birthweight infant?
USS
How can a brain haemorrage lead to hydrocephalus0
very large hemorrage
impairs drainage and reabsorption of CSF
causes CSF accumulation
may progress to hydrocephalys
How do you treat hydrocephalys?
venticuloperitoneal shunt
What is a likely consequence of post-haemorrhagic ventricular dilatation?
cerebral palsy
What is paraventricular leukomalacia
presence of multiple cystic lesions that occur due to periventricular white matter injur
What is necrotising enterocolitis
bacterial infection of ischaemic bowel wall
What are clinical features of NE
- stop tolerating feeds-
- milk aspirated from stomach
- vomiting (bile stained)
- abdo distension
- rectal bleeding
What are. x ray fts of NE
distended loops of bowel
thickening of bowel wall
intramural. gas
gas in portal tract
what is the risk of NE
progression to bowel perforation
How do you manage NE
STOP feeding
broad spec antibioticsa
surgery if bowel perforation / necrosis
parenteral nutrition, artificial ventilation
What are consequences of NE
development of strictures
malabsortpion
What is broncopulmonary dysplasia
chronic lung disease
when infants still havc an oxygen requirement. after 36 wks
How many infants become visibly jaundiced
50%
What is RBC span like in newborns
70 days
instead of 120
What is the level of bilirubin above which it becomes clinical jaundice
80mmol/L
What is kernicterus?
encepalopathy caused by deposition of unconjugated bilirubin in basal ganglia and brainstem
When does kernicterus occur?
when level of unconjugated bilirubin exceeds albumin binding capacity
Bilirubin is fat soluble, so it crosses the blood brain barrier
bilirubin has neurotoxic effects
\What are manifestations of kernicterus=?
irritability lethargy, poor feeding increased muscle tone baby lies with arched back (opisthotonos) seizures coma
What is opisthotonos?
baby lying with arched back
due to increased muscle tone in kernicterus
what do infants who survive kernicterus develop?
choreoathetoid cerebral palsy
learning difficulties
sensorineural deafness
how can we classify jaundice in neonates?
conjugated vs unconj
<24h
2 days to 2 weeks
>2 weeks
What are causes of jaundice <24h
HAEMOLYSIS:
- rhesus haemolytic disease
- ABO incompatibility
- G6PD deficiency
- Spherocytosis
OR CONGENITAL INFECTION
How do you detect jaundice secondary to ABO incompatibility?
Coombs test (direct antibody test) +
What are causes of jaundice 2 days - 2 weeks
- Physiological jaundice
- Breast milk jaundice
- dehydration
- infection
- Crigler-Najjar syndrome
What are causes of jaundice >2 weeks
unconjugated:
- breast milk jaundice
- infection
- congenital hypothyroidism
conjugated:
- BILIARY ATRESIA
- neonatal hepatitis syndrome
What other sx occur with obstructive jaundice?
pale stools
dark urine
hepatomegaly
poor weight gain
Where does jaundice start and where does it spread?
starts on neck and face
spreads to trunk and limbs
How do you assess for neonatal jaundice?
- Inspect baby in natural light
- Measure bilirubin
- serum bilirubin (<35 weeks OR jaundice developed in 24h)
- -transcutaneous bilirubin (>35 weeks OR jaundice developed >24h)
- Assess kernicterus risk
- Measure serum bilirubin every 6 hours
When can you stop measuring serum bilirubin every 6h=
Once it drops below treatment threshold or becomes stable / falling
When is someone at increased risk of kernicterus?
- serum bilirubin >340 mcmol/L in babies >37 weeks
- rapidly rising bilirubin > 8.5 mcmil/L per hour
- clinical its of acute bilirubin encepalopathy
How do you investigate underlying cause for neonatal jaundice
Htc Blood group of mother and baby DAT test (Coomb's) Consider: - FBC and blood film (e.g. hereditary spherocytosis) - Blood G6PD levels - microbio cultures of blood, urine, CSF
How do you treat neonatal jaundice
Phototherapy
Exchange transfusion
IVIG
What must you check for after phototherapy?
REBOUND bilirubinaemia
by measuring serum bilirubin 12-18 hours after stopping
What kind of dx is transient tachypnoea of the newborn?
Dx of EXCLUSION
What is the cause of transient tachypnoea of the newborn?
delay in reabsorption of liquid
What increases risk of transient tachypnoea of the newborn?=
C section
because liquid is not squeezed out of the lung
How do you manage transient tachypnoea of the newborn?
additional ambient oxygen
usually settles within first day of life
What is meconium?
dark green substance forming first faeces of newborn infant
How many babies pass meconium in utero ?
10-20%
What is meconium passed in response to?
GI maturation
foetal hypoxia
What is the issue with passing meconium in utero for foetus that is apnoea?
foetus starts gasping
it will aspirate on the meconium
What are the issues with aspirating on meconium ?
lung irritant
causes mechanical obstruction and chemical pneumonitis
lungs become overinflated, have patches of collapse and onsolitation
pneumothorax
How do you treat meconium aspiration?
Observation if no hx of GBS
Antibiotics (ampicillin/gent) if possible infection
Oxygen therapy and non-invasive ventilation (CPAP=
What is persistent pulmonary HTN of the newborn caused by?
Primary
Secondary, due to:
- birth asphyxia
- meconium aspiration
- septicaemia
- RDS
What does persistent pulmonary HTN of the newborn lead to
cyanosis soon after birth
due to increased vascular resistance causing L to R shunting of blood
How do you manage persistent pulmonary HTN of the newborn
Mechanical ventilation and circulatory support
Inhaled nitric oxide
Sildenafil (vasodilator)
High frequency (oscillatory) ventilation
ECMO
What is a diaphragmatic hernia caused by’
left sided herniation of abdominal contents through the diaphragm
This causes apex beat to be displaced to the right and poor air entry to the left
How do you confirm a diaphragmatic hernia
X ray
How do you manage a diaphragmatic hernia
large NG tube passed
suction applied to prevent distension of intrathoracic bowel
once stabilised, surgical repair
What are causes for early onset neonatal infection?
- ascending maternal infection
- through placenta (listeria, congenital viral)=
What are risk factors for early onset neonatal infection’
prolonged, premature rupture of membranes
chorioamnionitis
What antibiotics are started in early neonatal infection while awaiting culture?
benzylpenicillin
gentamicin
what are causes of late onset neonatal infection?
usually from surroundings e.g. indwelling catheters, invasive procedures
what are the paediatric sepsis 6
Give
- oxygen
- IV fluids
- antibiotics
Take:
- blood cultures, blood glucose, ABG/VBG
- experienced senior clinician involvement
- consider inotropes
What percentage of women are GBS carriers?
10%
How do you manage GBS infection in neonate?
IV benzylpenicillin
OR
ampicillin
How is listeria monocytogenes infection transmitted?
To the mother through food (unpasteurised milk, soft cheese, undercooked poultry)
Cause mild flu like sx to mother
Passes to foetus through placenta
Maternal infection could lead to abortion / preterm delivery / foetal sepsis
How do you manage listeria monocytogenes in pregnancy=
amoxicillin or co-trimoxazole
what are common causes of conjunctivitis and how do they present?
Common - wash with saline and water
Staph / strep - discharge and redness
gonococcal - purulent discharge, swelling of eyelids
chlamydia - purulent, swe.ling pof euyelid
What is cleft lip caused by?
Failure of fusion of frontonasal and maxillary processes
What is cleft palate caused by?
failure of fusion of palatine process / nasal septum
What is management for cleft lip / palate=?
specialist feeding advice
watch out for airway problem
pre surgical lip tapping to narrow the cleft
surgery for definitive repair
What is the Pierre robin sequence?
TRIAD
- microgniathia
- glossoptosis
- midline cleft of soft palate
What does Pierre Robin Sequence result in’
Feeding difficulty > failure to thrive
What does failure to thrive mean?
weight for age below the 5th percentile on multiple occasions
OR
weight deceleration that crosses 2 major percentile lines on growth chart
How should children lie in Pierre Robin sequence
on
On their front
due to risk of airway opnstricton
What is Hirschprung disease?
absence of myenteric plexus in the rectum
may extend along colon
What is rectal atresia?
absence of the anus at the normal site
what can you look for in a breastfeeding assessment
- inspect for tempioralis contraction
- ascultate sucking in cheek
