Neonatal Presentations Flashcards
What is meconium aspiration, how does it present and what is its DDx?
Meconium passes in utero = meconium stained amniotic fluid MSAF = airway obstruction, surfactant dysfunction, pulmonary vasoconstriction, infection, chem pneumonitis
S+S = Rapid or laboured breathing, chest wall recessions, grunting sounds, cyanosis, low apgar score (color, heartbeat, reflexes, muscle tone, respiration), limp body
DDx = Congenital Heart Disease with Pulmonary Hypertension, Sepsis, Surfactant Deficiency,
What is HDoN, how does it present and what is its DDx?
Rh-ve mother with Rh+ve baby, possible anti-D IgG Ab = subsequent preg these cross placenta = Rh haemolytic disease
S+S = jaundice, yellow vernix, CCF (oedema, ascites), hepatosplenomegaly progressive anaemia, bleeding, kernicterus (bilirubin brain damage)
DDx = thalassaemia, infection (CMV, toxoplasmosis), maternal DM
What is hypoxic-ischaemic encephalopathy, how does it present and what is its DDx?
Clinical syndrome of brain injury sec to hypoxic-ischaemic insult (cord prolapse, placental abruption, maternal hypoxia, inadequate postnatal cardio-pulmonary circulation)
S+S = resp depression (resus, IPPV), floppy, seizures, feeding probs, significant hypotonia, diminished deep tendon reflexes
DDx = Disorders of pyruvate metabolism, urea cycle defects, Zellweger syndrome, mitochondrial disorders
What is biliary atresia, how does it present and what is its DDx?
Biliary tree occlusion by being abnormally narrow, blocked, or absent at around 3w
S+S = jaundice, yellow urine, pale stools, splenomegaly
DDx = cholestasis, idiopathic neonatal hepatitis, neonatal hemochromatosis, toxoplasmosis, viral infections
What is sticky eye, how does it present and what is its DDx?
Commonly from a blocked tear duct (can be born with), infection
S+S = white or yellow discharge in the corner of the eye
DDx = ophthalmia neonatorum, chlamydia (swab)
What is are birth marks, how do they present and what a DDx?
Areas of discoloured and/or raised skin - pigment cells or blood vessels
VASCULAR = Infantile haemangiomas(rapid growth), capillary malformation (port-wine stain - red-pink stain on face/neck), nevus flammeus (forehead/eyelids/neck)
PIGMENTED = Café au lait spot (flat, ten), Slate grey nevus (mongolian blue spot - lower back), congenital nevus (mole)
What is the types of birth trauma and how do they present?
Caput Succedaneum = scalp bruising/oedema by vacuum/vaginal/uterus pressure (swelling)
Cephalohematoma = haematoma below the periosteum by rupture of blood vessels crossing the periosteum due to the pressure on the fetal head during birth (jaundice, swelling)
Chignon = oedema/bruising from ventouse delivery
Bruising and broken bones = tools, physical stresses of the passage through the birth canal or contact with the pelvis (not using limbs, malformations)
Subconjunctival haemorrhage = increased pressure (red eye)
Brachial plexus injury
- Erbs Palsy = C5, C6, waiters tip
Oxygen Deprivation = cord prolapse, premature loss of placenta (pale, floppy baby, CP)
What is a cephalohematoma, how does it present and what is its DDx?
Haematoma below the periosteum by rupture of blood vessels crossing the periosteum due to the pressure on the fetal head during birth
S+S = jaundice, bulges on head
DDx = forceps, vacuum
What is paediatric chronic lung disease, how does it present and what is its DDx?
Long-term breathing and lung problems in premature babies - from pressure/volume trauma from artificial ventilation, oxygen toxicity, infection
S+S = rapid breathing, flaring of the nostrils, grunting, chest retractions
Ix = CXR: ground glass
Continued need for positive pressure respiratory support or oxygen after a premature baby reaches 36 weeks of gestation
DDx = pneumonia, aspiration syndrome, SLE, CF
Mx = prophylactic palivizimab (try to prevent bronchiolitis)
What is erythema toxicum, how does it present and what is its DDx?
Therapy - hypersensitivity reaction
Common benign self-limiting, small papule/pustule surrounded by erythematous wheel
S+S = small papule/pustule surrounded by erythematous wheel
DDx = sepsis, staphylococcal folliculitis, acne neonatorum, pyoderma, congenital candidiasis, herpes simplex
What is paediatric failure to feed, how does it present and what is its DDx?
Causes = cleft lip/palate, premature suckling reflex
S+S = little interest in feeding, failure to thrive
DDx = congenital hypothyroidism, infant botulism, DS, diarrhoea, ear infections, coughs and colds, teething
What is a Hep B infection, how does it present and what is its DDx?
S+S = anorexia, nausea, malaise, vomiting, arthralgias, myalgias, headache, photophobia, pharyngitis, cough, coryza, jaundice, dark urine, clay-colored or light stools, and abdominal pain
DDx = autoimmune Hepatitis, paediatric Cytomegalovirus Infection, paediatric Hepatitis A, paediatric Hepatitis C, paediatric Herpes Simplex Virus Infection
What is paediatric hypothermia, how does it present and what is its DDx?
Body temp <36.5 = not drying, lack of skin-to-skin, lack of wrapping, cold delivery environment, no aftercare of newborn
S+S = weak cry, low energy level, lethargic, reddish cold skin, cool extremities and abdo, poor feeding, hypoglycaemia
DDx = haemorrhagic shock, medications (benzodiazepine, opioid, alcohol), carbon monoxide toxicity
What is Meconium delay, how does it present and what is its DDx?
Failure of the newborn to pass meconium within 24-48 hours
S+S = no meconium, poor feeding, lethargy, vomiting, diarrhoea, bloody stools, and constipation
DDx = Hirschsprung disease, meconium plug syndrome, meconium ileus, anorectal malformation,
What is Neonatal apnoea, how does it present and what is its DDx?
Unexplained episode of cessation of breathing for >20s
S+S = >20s, cyanosis, bradycardia
DDx = bacteraemia, bronchiolitis, bronchopulmonary dysplasia, croup, CHF, influenza, asthma, bacterial meningitis, head trauma, pneumonia, Guillain–Barré syndrome, prematurity, WPW syndrome
What is Neonatal collapse, how does it present and what is its DDx?
S+S = apnoea, limp child, pallor, bradycardia, cyanosis, collapse, cardiac/resp failure
DDx = congenital heart disease, sepsis, metabolic/endocrine disorders, head injury, hypothermia, intussusception, pneumothorax, pulmonary HTN, pneumonia, seizures, toxins
What is neonatal hypoglycaemia, how does it present and what is its DDx?
30 mg/dL (1.65 mmol/L) in the first 24 hours of life and less than 45 mg/dL (2.5 mmol/L) thereafter
Likely in = IGR, preterm (poor glycogen stores), mother with DM (hyperplasia of islet cells = increased insulin), large for dates, hypothermic, polycythaemia, illness
S+S = jitteriness, hypothermia, irritability, tremor, twitching, hypotonia, seizures, coma, irregular RR, apnoea
DDx = malnutrition, diarrhoea, glucagon deficiency, enzyme defects, congenital hyperinsulinism
Glucose intravenous infusion 10%
What is ABO/Rh incompatibility, how does it present and what is its DDx?
Mother’s immune system reacts and make Ab against her baby’s RBCs
S+S = blood in urine, fever/chills, SOB, tachy, vomiting , jaundice
DDx = acute anaemia, parvovirus B19 Infection, CMV, Hydrops Fetalis, toxoplasmosis
Outline ambiguous genitalia
Infant’s external genitals don’t appear to be clearly either male or female caused by atypical development of chromosomal, gonadal, or anatomical sex
Includes syndromes such as Turner syndrome (45,X with one absent sex chromosome) and Klinefelter syndrome (XXY with one additional X chromosome).
Mosaicism occurs when more than one type of chromosomal arrangement is present (45,X/46, XY)
46,XX DSD are conditions characterised by excess exposure to androgens. Over 95% of causes of ambiguous genitalia with a 46,XX genotype are due to congenital adrenal hyperplasia secondary to 21 hydroxylase deficiency.
46,XY DSD can be due to several aetiologies and usually requires a more extensive diagnostic evaluation.
Outline congenital adrenal hyperplasia
Caused by a defect in 21-hydroxylase in the steroid hormone synthesis pathway in the adrenal gland - leads to excess amounts of male hormones being produced by the adrenal glands
Causes females to be masculinized - large clitoris, fused labia
Autosomal recessive
Involves a deficiency of an enzyme involved in the synthesis of cortisol, aldosterone, or both
Outline inborn errors of metabolism
Types = PKU, ornithine transcarbamylase deficiency, methylmalonicaciduria, medium-chain acyl-CoA dehydrogenase (MCAD) deficiency, galactosemia, and Gaucher’s disease, G6PD def
Many congenital metabolic diseases are now detectable by newborn screening tests
Mx = restrictive diet, enzyme replacement, gene therapy, organ transplantation
Discuss neonatal HIV
Antenatal screening for HIV is offered at antenatal booking appts
The majority is from mother-to-child transmission (MTCT)
- VL <50 = vaginal delivery
- VL >50 = prelabour Caesarean section (PLCS)
In children over 1 year of age, treatment is based on the child’s age, CD4 cell count, viral load, and symptoms.
To prevent transmission of infection, neonates born to HIV +ve mothers should be given post-exposure prophylaxis as soon as possible after birth, but starting no later than 72 hours after birth
Exclusive formula feeding
Outline neonatal intraventricular haemorrhage
Bleeding into the ventricles in the brain, from the choroid plexus under the ventricles
Condition occurs most often in babies that are born premature - under devel blood vessels, cant regulate own BP
Ix = cranial USS
S+S = apnoea, brady, cyanosis, high-pitched cry, bulging fontanelles, lethargy
Comp = clotting, RICP, parenchymal bleed (cortical damage = CP)
Discuss retinopathy of prematurity
Blood vessels grow abnormally and randomly in the eye, these tend to leak or bleed, leading to scarring of the retina
Link to over-oxygenation
When the scars shrink, they pull on the retina, detaching it from the back of the eye = blindness
Outline neonatal talipes
Clubfoot = birth defect that can affect one or both feet, entire foot inverted, supinated, forefoot adducted, heel rotated inwards, plantar flexion
Idiopathic
Ponsetti method = (passive) manipulating the foot into a better position, then putting it into a cast. This is repeated every week for ~5-8w. After the last cast comes off, most need a minor operation to loosen the Achilles tendon
What is neonatal jaundice, its causes and presentation?
Jaundice of the white part of the eyes and skin in a newborn baby due to high bilirubin levels
Hx = feeding (type, well weight loss), nappies, birth gestation, sepsis, antiD use, FH: anaemia, HDoN, HA, hypothryoid
Causes =
- Physiological: never first 24h, D2-14 (breakdown of fetal Hb as it is replaced with adult Hb, relatively immature metabolic pathways of the liver)
- Early: first 24h, haemolytic disease, congenital infection, ABO incompatibility, Rh disease
- Prolonged: >2w in term baby, >21d preterm, UTI, hypothyroidism, biliary atresia
- Conjugated hyperbilirubinemia: infection, CF, biliary atresia (pale stools, dark urine)
S+S = yellow skin/sclera (blanch the nose), excess sleepiness, poor feeding, altered muscle tone
How should neonatal jaundice be Ix?
Bilirubinometer = serum bilirubin
Direct coombs test, blood group, LFTs, FBC, blood film, enzyme def (G6P-D), sepsis investigations, split bilirubin (conjugated vs non), TFT, urine analysis, U+Es, INR
USS = biliary atresia
How should neonatal jaundice be Mx?
More frequent feeding (monitor nappies) = more bowel movements, which helps to eliminate excess bilirubin
Refer bilirubin chart
- Phototherapy = 24-48h, light is absorbed by the skin and helps break down the bilirubin
- Exchange transfusions via umbilical artery or vein
Other = IV access, Abx (cover sepsis), surgery (biliary atresia)
What are the possible complications of neonatal jaundice?
Seizures
CP
Kernicterus = unconjugated bili can cross BBB, bilirubin-induced encephalopathy (fever, seizures, high-pitched crying) - effects basal ganglia, brainstem CN nuclei, hippocampus
What is the definition of prematurity and its RF?
Delivery before 37w gestation
RF =
- Multiple pregnancy
- Smoking and illicit drug use in pregnancy
- Being under or overweight in pregnancy
- Early Pregnancy (within 6m of previous pregnancy)
- Problems involving cervix, uterus, placenta, including infection
- Certain chronic conditions such as DM and HTN
- Physical injury/trauma
How is prematurity managed?
Assessment =
- blood gas (resp, metabolic state)
- FBC ( infection, thrombocytopenia, anaemia)
- U+E (renal)
- blood group/Direct Antiglobulin Test (blood transfusion)
- CXR (?resp support)
- AXR (?necrotising enterocolitis)
- Cranial ultrasound scan (?neurological insults from haemorrhagic, ischaemic and infective)
Antenatal steroids
Magnesium sulphate - neuroprotective
What are the possible complications of prematurity?
Resp = Respiratory distress syndrome, Surfactant deficient lung disease, Chronic lung disease/ Bronchopulmonary dysplasia, recurrent apnoea
CVS = hypotension, perfusion abnormalities, PDA
Neuro = IVH, seizures, post haemorrhagic ventricular dilatation, neurodevelopmental delay, CP
GI = Immature gut causing feed intolerance, necrotising enterocolitis (NEC)
Renal = immature renal function
Metabolic = jaundice, hyperglycaemia, hypoglycaemia, Inborn errors of metabolism
Immune = sepsis, increased risk of infection due to central lines and multiple procedures
Eyes = retinopathy of prematurity
What is IUGR and its causes?
Baby is smaller than it should be because it is not growing at a normal rate inside the womb
Weight below the 10th percentile
Aetiology =
- MATERNAL: DM, HTN, heart disease, rubella, cytomegalovirus, toxoplasmosis, syphilis, kidney disease or lung disease, malnutrition, anaemia, smoking, drinking alcohol, or abusing drugs, placental insufficiency
- FETAL: congenital, antiphospholid Syndrome
How should IUGR be investigated?
Serial USS, fetal karyotype for chromosomal abnormalities, maternal infection including TORCH (Toxoplasma, others, rubella, cytomegalovirus, and herpes), syphilis, detailed fetal anatomical survey, TIFFA scan (targeted imaging for fetal anomaly) and uterine artery Doppler, by a fetal medicine specialist if severe SGA is identified at the 18–20 week scan
How should IUGR be Mx?
Regular scans
CTG monitoring
Early delivery
How does neonatal group B strep infection present?
One in three women carry group B streptococci vaginally, which can infect the amniotic fluid even if the membranes are intact, or can infect the baby during delivery, causing sepsis, pneumonia, or meningitis.
S+S = fussy, very sleepy, respiratory distress, tachypnoea, grunting, seizure, sepsis, pneumonia
How is neonatal group B strep infection Mx?
Maternal IV Abx during labour
Newborn intensive care unit (NICU)
IV Abx = benzylpenicillin with gentamicin
7-14d Abx if meningitis present
How is suspected neonatal GBS infection Ix?
Blood/CSF culture
BP
BM
What are the possible neonatal infection?
Congenital rubella Syphilis Toxoplasmosis CMV Herpes simplex viruses HIV Hepatitis B Group B streptococci Enteric gram-negative organisms (primarily E. coli) Listeria monocytogenes Gonococci Chlamydia
At increased risk as IgG transferred across placenta in the last trimester
How does a neonatal infection present?
vomiting or poor feeding, increased sleepiness or lethargy, fever or hypothermia, tachypnea, rashes, diarrhea, abdominal distention
How does a neonatal infection present?
Vomiting or poor feeding, increased sleepiness or lethargy, fever or hypothermia, tachypnea, rashes, diarrhea, abdominal distention
How is a neonatal infection Dx?
Blood culture
Outline neonatal RDS
Surfactant prod after 30w
Prematurity = decreased reduction in surface tension = alveoli collapse = increased energy required for efficient respiration. Pulmonary oedema devel, further reducing lung compliance
= hypoxia, CO2 retention, acidosis
S+S =grunting, accessory muscles, nasal flaring, tachypnoea
Tx = maternal dexamethasone, endotracheal surfactant, CPAP, Abx
Outline respiratory distress
Terminal bronchioles is where you start making T2 pneumocytes
Premature = undevel/not developed yet
S+S = tachypnoea, ICR, SCR, tracheal tug, SOB, end stage: cyanosis, apnoea
Mother given 2 doses steroids
Tx = surfactant via ET tube