Neonatalogy Flashcards
What are three severeties of HIE? What characterises them?
Mild - irritable neonate, increased response to stimulation. Staring. Impaired feeding. Most recover.
Moderate - abnormal tone/movement. Reduced feeding. Seizures
Severe - no normal spontaneous movements to pain. Hypo/hypertonia. Seizures prolonged and refractory to treatment. Multi-organ failure
What is the mortality rate in severe HIE?
30-40%
Management for HIE
Hypothermic cooking shown to reduce brain damage
What is the prognosis of HIE features persisting beyond 2 weeks
Poor prognosis
What may bilateral abnormalities in the basal ganglia/thalamus suggest in suspected HIE?
HIGH risk of later cerebral palsy
Causes of HIE
Uterine rupture Plaental abruption IUGR Failure to breathe Cord compression Cord prolapse
Jaundice <24 hours causes
SEPSIS until proven otherwise
Haemolysis (ABO incompatibility, Rhesus disease, G6PD deficiency)
Physiological
Jaundice 24h-2 weeks causes
Physiological (breakdown product of excess Hct)
Breastfeeding
Haemolysis (ABO incompatibility, Rhesus disease, G6PD deficiency)
Polycythaemia
Infection
Jaundice >2 weeks high unconjugated causes
Haemolysis
GI obstruction
Hypothyroid
Jaundice >2 weeks high conjugated causes
Obstructive picture
- Biliary atresia
- Choledochal cyst
Hepatitis
- Infection
- a1 antitrypsin
What is the commonest indication for a paediatric liver transplant?
Biliary atresia
What is biliary atresia?
Destruction/absence of extrahepatic biliary tree and intrahepatic ducts
Clinical features of biliary atresia
Normal birth weight but FTT
Pale stools, dark urine
Jaundice
Hepatomegaly (then splenomegaly)
Ix for biliary atresia
USS abdomen TIBIDA scan (good uptake but no excretion into bowel) Liver biopsy
Management of biliary atresia
Surgical bypass hepatoportoenterostomy (Kasai)
Ursodeoxycholic acid (bile movement)
Nutritional supplementation incl vitamins ADEK
Prophylactic abx to reduce risk of cholangitis
Signs of resp distress in a neonate
Tachypnoea Increased WOB Grunting Recessions Cyanosis
What is the primary cause of transient tachypnoea of the newborn?
Delay in lung liquid reabsorption
In which type of birth is TTotN more common?
CS
CXR TTotN
Fluid line in horizontal fissure
What percentage of babies pass meconium before birth?
8-20%
Three severities of meconium aspiration
Mild
Moderate
Severe
What other resp disorder are babies who aspirate meconium more likely to suffer from?
Pneumothorax
CXR features of meconium aspiration
Features of sepsis - unstable temperatures, resp distress, jaundice, slow CRT, apnoea
Overinflated lungs
Collapse
Consolidation
Treatment of meconium aspiration
IF RFFS:
- IV ampicillin and gentamicin
Risk factors for sepsis
Chorioamnionitis PROM PPROM Maternal fever during labour FHR abnormalities Oligohydramnios
What are the risk factors for pHTN?
RDS
Pneumothorax
Meconium aspiration
L to R shunt
Ix for pHTN
Urgent ECHO (congenital lesions)
Mx of pHTN
Mechanical ventilation and circulatory support
Inhaled nitric oxide and sildenafil (viagra) - both vasodilators
To consider ECMO
Complications of pHTN (with patent duct)
Eisenmenger’s syndrome - L to R shunt becomes R to L shunt
What is a diaphragmatic hernia?
L sided herniation of abdo contents through posterolateral foramen of diaphragm
Disaphragmatic hernia signs
Apex beat and HS displaced to R – pulmonary hypoplasia
Ix for suspected diaphragmatic hernia
CXR/AXR
Mx diaphragmatic hernia
Large NGT w/ suction applied (to prevent dilatation)
Surgical repair once normal pulmonary pressures are maintained
Management of infant born to HbsAg positive mother
Vaccinaton shortly after birth
AND HepB Ig if at risk
Management of infant with active HepB
Supportive therapy
Immune active phase - treat with interferon/tenofovir disoproxil
Management of pregnant mother HbsAg positive
Antiviral monotherapy (tenofovir disoproxil) if viral load >200,000
Treatment/advice for rubella
Rest, fluids, paracetamol
AVOID other pregnant women for 6 days after rash onset
IM immunoglobulin
When is the highest risk of rubella transmission?
EARLY pregnancy (<20 weeks) - 8-10 weeks worst
Symptoms of rubella (in mother)
Rash (starting on face, spreading to body)
Post-auricular lymphadenopathy
Three primary features congenital rubella syndrome
Deafness
Cataracts
Cardiac problems - PDA common
Which cardiac issue is common in congenital rubella syndrome?
PDA
Which neonates are at highest risk of hypoglycaemia?
IUGR
GDM
Prem
Hypothermic
Features hypoglycaemia neonate
Jittery, irritable, apnoea, lethargy, drowsy, seizures
What blood glucose is desirable for neonates to ensure normal neurodevelopmental outcome
> 2.6
What is a complication of prolonged and symptomatic hypoglycaemia in the neonate?
Neurodisability
How is neonatal hypoglycaemia managed?
Glucose IV infusion (until BM >2.6)
Early/more frequent feeding
Glucagon/steroids if necessary
What blood glucose is desirable for neonates to ensure normal neurodevelopmental outcome
> 2.0 pre feed
What is early onset sepsis?
Within 48 hours of birth
How is neonatal hypoglycaemia managed?
Glucose IV infusion (until BM >2.0)
Early/more frequent feeding
Glucagon/steroids if necessary
What is late onset sepsis?
After 48 hours of birth
Primary causes late onset sepsis
Nosocomial - lines, catheters, ventilation
Commonest early onset sepsis causative organisms
GBS
Listeria
E.coli
Commonest late onset sepsis causative organisms
Coagulase negative staph.
E.g. staph epidermis
Abx for early onset sepsis organisms (+ve and -ve)
+ve benpen, amoxicillin
-ve gentamicin
Abx for late onset sepsis organisms (+ve and -ve)
vanc/gent/fluclox
% of pregnant women with GBS (vaginal/faecal)
30%
When are abx appropriate (for mum and baby) in GBS positive mothers?
IF:
- Suspected sepsis in mother (intrapartum abx once labour starts)
- Previous baby with GBS (intrapartum abx)
For baby if increased risk and/or abx not started within 4 hours before birth
Treatment for listeria
Amoxicillin/cotrimoxazole
Features of listeria infection
Mec in a preterm baby (unusual).
Rash
Septicaemia
Conjunctivitis in newborn
Troublesome discharge,
Red
Itchy eyes
Commonest causative agent in conjunctivitis <48hr after birth
Gonococcal
Conjunctivitis causative agent
Chlamydia trachomatic
Ix/Mx for conjunctivitis
Swab
Abx - erythromycin
Treatment of omphalitis
Aim to prevent involution by granuloma
AgNo3
Highest risk for transmitting HSV
Mother with primary genital herpes infection within 6 weeks of birth
What is the risk of a mother with primary genital herpes infection transmitting to infant in vaginal delivery?
40%
Management of mother with primary genital herpes infection within 6 weeks of delivery
ELCS
IV aciclovir for mother
IV aciclovir for baby on delivery
Treatment for congenital CMV
Ganciclovir
When does necrotising enterocolitis present?
First few weeks of life
What is necrotising enterocolitis?
Bacterial invasion of ischaemic bowel wall
Which group of neonates are more likely to develop necrotising enterocolitis?
Those drinking cow’s mil formula
Clinical features of necrotising enterocolitis
Reduced feeding Milk aspiration Bile stained vomit Abdominal distension (tense, shiny skin) PR bleed BOWEL PERFORATION - SHOCK
AXR features of necrotising enterocolitis
Distended bowel loops, thickened bowel wall, intramural gas
Mx necrotising enterocolitis
STOP oral feed
Broad spec abx - vanc/cefotaxime
TPN
Surgery
Commonest cardia lesion in preterm babies
PDA
Management of PDA
Medical
- Prostacyclin synthetase inhibitor
- IV indomethacin
- Ibuprofen
Surgery - balloon
How much should a preterm baby be feeding?
60-90ml/kg/day
How much should a term baby be feeding?
90-120ml/kg/day
Baby with poor feeding maintenance fluids
2/3
Why is haemorrhage common (25%) in vLBW naeonates?
Fragile blood vessels around the germinal matrix above the caudate nucleus
Name one (resp) risk factor for neonatal naemorrhage?
Pneumothorax
Three types of brain injury in preterms
- Haemorrhage
- Ventricular dilatation (blockage of CSF drainage) –> hydrocephaly
- Periventricular leukomalacia
What clinical features does periventricular leukomalacia later present with?
Spastic diplegia
What % of vLBW babies have retinopathy of prematurity
35%
What is the pathophysiology of retinopathy of prematurity?
Vacular proliferation = detachment, fibrosis and blindness
Mx of ventricular dilation
Ventriculo-peritoneal shunt
Mx of retinopathy of prematurity
R/f to ophthalmology
Laser therapy
Pathophysiology of respiratory distress syndrome
Reduced lung surfactant (type II pneumocytes) = reduced surface tension = alveolar collapse = impaired gas exchange
Is RDS more severe in male or female preterms?
Male
How can RDS be prevented?
Antenatal steroids (within 7 days of delivery)
Features of RDS
All within 4 hours of birth:
- Tachypnoea
- Cyanosis
- Increased WOB
- Expiratory grunt
CXR features of RDS
Granular/ground glass appearance
Air bronchograms
Management of RDS
O2 ventilation (CPAP)
Exogenous surfactant via an ET tube
Supportive preterm therapy
Pathophysiology of pneumothorax in preterm
Air from overdistended alveoli tracks into interstitium
Risk factors for pneumothorax
Ventilation
RDS
Infection (mec aspiration)
Ix for pneumothorax
Transillumination
CXR
Mx of pneumothorax in preterm
O2
Decompression
Chest drain
How can pneumothoraces be prevented in preterm babies?
Ventilate at lowest possible pressure
What is apnoea in the neonate?
Cessation of breathing for >20 seconds
What is the commonest cause of apnoea/bradycardia in preterm baby?
Immaturity of respiratory control
How is apnoea/bradycardia in preterm baby managed?
Physical stimulation
Caffeine
CPAP
What is bronchopulmonary dysplasia?
Chronic lung disease - continued O2 requirement beyond 36/40
CXR features of bronchopulmonary dysplasia
Widespread opacification
Management of bronchopulmonary dysplasia
Weaning from ventilation –> CPAP –> ambient O2
Management of GORD - common comorbidity
What are infants with bronchopulmonary dysplasia more likely to suffer from?
GORD
Increased risk pertussis/RSV infection
Management of bronchopulmonary dysplasia
Weaning from ventilation –> CPAP –> ambient O2
- Steroids after 7/7 if still on ventilator
- Diuretics if on ventilator
- Caffeine
- Nitric oxide
(Management of GORD - common comorbidity)
Cause of cleft lip
Failure of fusion of frontonasal and maxillary processes in embryogenesis
Cause of cleft palate
Failure of fusion of the palatine processes and the nasal septum
What are cleft lip/palate associated with?
Maternal anti-convulsants
Chromosomal abnormalities
Management of cleft lip/palate
Specialised feeding advice
Observe for airway problems (Pierre Robin sequence)
SLT/orthodontists
Surgery = definitive
Clinical features of Pierre-Robin sequence
Micrognathia, posterior displacement of the tongue and midline cleft of the soft palate
Presentation of Pierre-Robin sequence
Feeding difficulty --> FTT Airway difficulty (cyanotic episodes)
– as tongue falls back
Mx of Pierre-Robin sequence
Nasopharyngeal airway
Maintaining prone position
Abx for GBS
Benpen and gent
Mx haemolytic disease of the newborn
Anti D Ig at 28 weeks and birth
- Exchange transfusion if severe
- Phototherapy
- IVIG
Mx toxoplasmosis in newborn
Pyrimethamine, sufadiazine, calcium folinate
+ prednisolone
RFs for RDS
Prematurity, male, CS, GDM, multiple pregnancy
Complications of mec aspiration
Infection (sepsis)
Persistent pHTN of newborn
Most common cardiac defect in T21?
AVSD
When is benpen and gent coverage for suspected sepsis switched over to cefotaxime?
Once they have been out of the hospital and been exposed to a broader range of pathogens
Why do neonates have cefotaxime rather than ceftriaxone? When?
Ceftriaxone can cause biliary sludging
After 1 month
Why do you need an anaesthetist if giving prostin (prostaglandin) for a duct-dependent circulatory problem?
Respiratory depression (apnoea)
Investigations for suspected metabolic problems
Gas - LDH (mitochondrial)
Ammonia (urea cycle)
What might a raised ammonia indicate?
Urea cycle disorder
