neonate, community, emergency Flashcards
with regards to blood sugars, when is a baby allowed home
when CBG is stable after 2 feeds
if symptomatic of hypoglycaemia or very low sugars, what is given
10% dextrose
signs of hypoglycaemia in neonate
weak cry, apnoea, hypothermia, irritation, jittery, hypotonia, poor feeding
symptoms of fragile X
learning difficulties, microcephaly, big testis, mitral valve prolapse
signs of patau T13
cleft palate, polydactyl, small eyes, microcephaly
signs of Edwards T18
rocker bottom feet, low set ears, overlapping fingers and micrognathia
is intellect normal in turners
YES
what investigations do you do for paracetamol OD
paracetamol level 4 hr from ingestion, U+E, salicylate level, LFT, glucose, clotting screen, blood gas
what do you do if a paracetamol OD presents within 8 hours
take bloods at 4 hr
what do you do if a paracetamol OD presents > 8 hr
if taken >150mg/kg start Tx straight away, otherwise wait for paracetamol levels
what do you do if someone presents >24 hours after OD
start Tx if they have any symptoms
criteria for liver transplant
24 hours after OD:
1) pH <7.3
OR all three of
1) deranged clotting (prothrombin time)
2) creatinine > 300
3) grade III or IV encephalopathy
phenotypical features of someone with FAS
smooth philtrum, low set ears, short palpebral fissures, microcephaly
-+signs of withdrawal on birth
a cause for GDD is rett syndrome, what is this?
rare neurological disorder that affects young girls and they lose previously acquired skills like purposeful hand movements
-microcephaly + hand wringing
congenital cause of GDD
spina bifida
broad causes for GDD
-neurological
-infection
-neuromuscular disorders
-genetic disorders
-metabolic disorders (PKU)
-FAS
what investigations do you do firstline for a global developmental delay
-FBC and haemantics
-U+E
-CK
-TFT
-LFT (metabolic disorder)
-hearing tests
then second line do karyotyping
what is the limit age of a milestone
the age at which the milestone should be met, this is normally 2 standard deviations form the median age of acquisition
what’s the social red flag for developmental milestone
no smile by 10 weeks
what’s the gross motor milestone red flag
not sitting unsupported by 12 months
what does a health visitor do
they assess a Childs development at 6/8 weeks, 9-12 months and 2-2.5 years. They provide support and encouragement to families in the early years
spasticity is velocity
dependent
what is dyskinetic cerebral palsy
involuntary, unpredictable movement with fluctuating muscle tone
complications of CP
epilepsy, hip pain/dislocation, drooling, pain, learning difficulties
signs of PKU
hypopigmentation, learning difficulties, microcephaly
when is the newborn exam done and then when is the infant exam done
newborn at 72 hours and then infant at 6-8 weeks
shaken baby syndrome is a triad of
retinal haemorrhage, subdural haematoma and encephalopathy
in a child < 3months, presenting with a fever, what investigations do you do?
blood culture, urine dip, FBC, CRP, stool culture, CXR, lumbar puncture
signs of TTN on CXR
fluid in horizontal fissure and hyperinflation of the lungs
RF of neonatal sepsis
PROM, mum pyrexia in labour, premature, LBW
Mx of neonatal sepsis
IV benzylpenicillin with gentamicin, monitor CRP at 24 hours to check progress
what’s early vs late neonatal sepsis
early = birth - 72 hours ]
late = 72 hours - 28 days
causes for late onset neonatal sepsis
organisms from environment like staph epidermis or pseudomonas or klebsiella
sepsis 6 in children
1) get senior help
2) consider early inotropic support
3) give Abx
4) give fluids
5) give O2
6) take bloods and cultures
how do you treat late onset neonatal sepsis
ceftriaxone and amoxicillin
red flags of neonatal sepsis
apnoea, seizures, resp distress starting > 4 hours after birth
RF for neonatal jaundice
sibling being jaundice + requiring phototherapy, prem, exclusively breastfed
causes for jaundice >14 days (or >21 days if preterm)
-physiological
-biliary obstruction
-neonatal hepatitis
-hypothyroidism
-infection
-gilberts
when must a serum bilirubin be measured
if baby <35/40 weeks, TCB >250 or if >24 hours old
what IX do you do if baby if jaundice
serum bilirubin, measure blood group of mum and baby and check ABO and RhD, TFT, Coombs LFTs, TFT, G6PDH, percutaneous liver biopsy with intraoperative cholangioscopy if delayed
how does phototherapy work for jaundice
the blue/green light converts the bilirubin into lumirubin which is easily soluble and easily excreted
if a baby starts showing signs of bilirubin encephalopathy (kernicterus) what needs to happen
exchange transfusion
how does kernicterus present
lethargy, hypotonia, poor suck reflex which then progresses to hypertonia, seizures and a high pitched cry
three cardiac causes of cyanosis in the neonate
tricuspid atresia, TOF, TGA
apart from cardiac causes of central cyanosis in the newborn, give some other causes
1) choanal atresia (cyanosis will be worse when baby feeds)
2) micrognathia
3) congenital lobar emphysema (hyperinflation of one or more pulmonary lobes which then compresses the surrounding lung)
4) CDH (causes pulmonary hypoplasia)
5) apnoea
6) SMA type 1
7) infection
what are the issues with neonatal resuscitation
hypoxia, babies have a large SA to weight ratio so get cold very easily and are born wet
how many times do you repeat inflation breaths in neonatal resuscitation
after drying baby you give 5 inflation breaths, then reassess and then give another 5 inflation breaths
when do you start CPR on neonate
if after 30s of ventilation, HR is still below 60 or not detectable
how often do you reassess for HR and chest movement in neonatal resuscitation
every 30 seconds (at rate of 3:1)
where is a cephalohaematoma vs a caput succadeneum
cephalohaeamtoma is subperiosteal
caput succadeneum is extraperiosteal
what is the definition of apnoea
periods where baby stops breathing for 20s + or less time if there is concurrent bradycardia
why does apnoea of prematurity occur
immature respiratory control centre
apart from prematurity, what are some other causes of apnoea
infection (sepsis and whooping cough), GORD, anaemia, hypoglycaemia
MX of apnoea
1) caffeine therapy (stimulates the peripheral chemoreceptors)
2)apnoea monitors in NICU which stimulate baby to start breathing again by tactile stimulation
Rf for SIDS other than cosleeping and parenteral smoking
prone sleeping, hyperthermia
protective factors of SIDS
breastfeeding, room sharing and use of dummies
although SIDS normally affects premature babies, it can also affect term babies - what is a risk factor for this?
maternal diabetes
Xray appearance of surfactant deficiency
ground glass appearances
complications of surfactant deficiency
pneumothorax, apnoea, IVH, chronic lung disease of prematurity
what causes PPHON
MAS or infection (it is caused by the vascular bed being remodelled. Get raised R side pressure in heart and R-L shunting if cardiac defect)
what are the complications of the baby passing meconium in utero
1) pneumonitis
2) can cause a pneumothorax
RF for MAS
gestation >42 weeks, foetal distress, oligohydraminos, IUGR, maternal hypertension, OC
how can MAS be distinguished from TTN
TTN clears spontaneously
what does a chest XR show for MAS
hyper inflated lung fields and patchy pulmonary opacities
how can we avoid MAS
avoid post dates gestation and fetal hypoxia and if there is evidence of meconium stained liquor then do suctioning
Mx of MAS post delivery
suction, O2, Abx for pneumonia cover, surfactant bolus
Rf for premature baby
previous premature, multiple preg, being underweight or overweight in pregnancy, smoking or illicit drug use, incompetent cervix
what can be done to prevent preterm labour
if the cervix if <25mm then can give vaginal progesterone or do cervical cerclage
what Ix may you do once a preterm baby is born
cranial US to check for IVH, blood group and Coombs test, FBC, urea, creatinine, CRP, CXR
list some complications of the preterm infant
IVH, NEC, jaundice, RDS, immature renal function, sepsis, immature skin barrier, immature thermoregulation and retinopathy of prematurity
long term complications of the preterm infant
-neurodevelopment outcomes
-chronic lung conditions
-hearing and visual impairment
RF of retinopathy of prematurity (new vessels form in response to hypoxia)
premature, LBW and artificial ventilation
Tx of retinopathy of prematurity
laser photocoagulation of intravitreal VEGF inhibitors
pathophysiology of retinopathy of prematurity
in utero the retinall blood vessels are stimulated by hypoxia. When baby is supplemented with oxygen this signal is removed and then when the hypoxia environment returns, the retina responds by producing excessive blood vessels
complications of CDH
pulmonary hypoplasia and pulmonary hypertension
6 advantages of breast feeding
1) free
2) lower rates of postnatal depression
3) reduced rates of allergies in adult
4) reduced risk of NEC
5) less likely to become obese as adult
6) IgA transfer
what factors determine prognosis in a congenital diaphragmatic hernia
1) liver position
2) lung-to-head ratio
drugs which can cause cleft lip/palate
phenytoin and ondansetron
what can cause cleft lip/palate
drugs, genetic syndromes like di George, family history
what causes cleft lip
failure of the nasal prominences and the maxillary prominences to fuse properly
what causes cleft palate
failure of the palatine processes and nasal septum to fuse
complications of cleft lip/palate
glue ear, feeding problems, psychosocial
who should treat people with cleft lip
specialist cleft lip service (MDT)
when is cleft lip vs cleft palate surgery done
lip - 3-6 months
palate 6-12 months
when does face Development begin in embryology
week 4
describe pharyngeal arches
there are 6 pharyngeal arches - made from development of mesoderm. The inner surface is endoderm, the bulk of tissue is mesoderm and the external surface is ectoderm. Each is associated with a cranial nerve, artery and cartilage.
The 5th regresses very quickly after development. On the inner surface there are pharyngeal pouches. The outer surface there are pharyngeal clefts. Only the first pharyngeal cleft becomes a structure in the adult and this becomes the external auditory meatus.
The face and palate form from the first pharyngeal arch and neural crest cells
what forms from the endoderm, mesoderm and ectoderm (this trilaminar disc formed in gastrulation)
endoderm - epithelial surface of GI tract and resp tract
Mesoderm - notochord, MSK and circulatory system
ectoderm - skin, nervous system and eye
what causes branchial cyst to develop
failure of the 2nd pharyngeal cleft to obliterate
RF of HIE
blood pressure extremes in mother, CHD, problems during labour, infection
what stages HIE
sarnat staging
criteria to use therapeutic hypothermia for HIE
it must be moderate or severe and mustt be done in the 6 hours after birth. The infant must be>36 weeks
monitoring done in therapeutic cooling
EEG and cardioresp monitoring
compilations of therpeutic cooling
arrhythmias, electrolyte imbalance, infection, bleed risk, PPH
when to suspect HIE
acidotic on blood gas, poor APGAR score
what are the levels like for a Down syndrome screening quadruple test
bHCG - high
AFP - low
unconjugated oestradiol - low
inhibin A - high
in the quadruple test what causes an isolated rise in AFP
neural tube defects
screening which is done on a Down syndrome baby once born
echo, heel prick test (looking at hypothyroidism!), hearing and eye sight
complications of downs
subfertiity, AML, Alzheimer’s, recurrent ear infections, sight problems, AVSD, hirschsprungs, duodenal/anal atresia
features of fragile X
X linked dominant
-autism, learning difficulties
-large low set ears
-large testis
features of fetal alcohol syndrome
flat philtrum, learning disabilities, short palpebral fissure, microcephaly, growth retardation
features of pataus (T13)
cleft palate, polydactyly, microcephaly
features of Edwards (T18)
rocker bottom soles, low set ears, micrognathia, overlapping fingers
features of noonans (turners in boys)
webbed neck, pectus excavatum, pulmonary stenosis
how might you treat turners
give growth hormone, monitor heart and may give oestrogen replacement
neurological causes for GDD
spina bifida, IVH
Rett –> acquired
causes for GDD
neurological
infection
neuromuscular disorders
genetics –> downs, fragile X
Metabolic - PKU
Prematurity
Investigations for GDD
1) FBC and haemantics
2) U+E
3) CK
4) TFT
5) LFT
6) Vit D
7) Hearing
2nd line –> karyotyping and DNA analysis
what are the red flags of development
-not smiling by 10 weeks
-not sitting unsupporting by 12 months
-hand preference by 12 months
-speech and language - not knowing 2-6 words by 18 months
what is the purpose of a healthy visitor
assess a Childs development at 6/8 weeks / 9/12 months and 2-2.5 years + PROVIDE SUPPORT AND ENCOURAGEMENT TO FAMILIES IN THE EARLY YEARS
What is the definition of cerebral palsy
permanent, not progressive neurological damage that causes a gross motor delay
what are some early signs of cerebral palsy
poor feeding, abnormal reflexes and abnormal muscle tone
what happens in dyskinetic cerebral palsy
involuntary, uncontrolled, recurring movements with fluctuating muscle tone and persistent reflexes
what is used for pain in CP
diazepam
what is used for spasticity in CP
baclofen
complications of CP
hip dislocation, excess salivation, epilepsy, constipation
what investigation should be done if suspecting NAI
skeletal surgery –> this should then be repeated after 11-14 days
and CT head if any signs of head injury
what is checked in the newborn exam
eyes, heart, hips and testes
when should a vaccine be delayed
when child is unwell with fever or when on immunoglobulin therapy
example of inactivated (whole killed) vaccine
polio
when is MMR (live vaccine) given
at 1 year and before school
when is the pneumococcal vaccine given
at 12 weeks and one year
when is the rotavirus given
8 weeks and 12 weeks
when is the MMR vaccine given
at 1 year and at preschool
what vaccines are given at 1 year
Hib/Men C
MMR
PCV
Men B
when is the Men B vaccine given
8 weeks and 16 weeks
what vaccines are given at 3-4 years
MMR and 4 in 1 booster
signs of achondroplasia
short limbs, mid face hypoplasia and large head with frontal bossing
RF for ASD
advanced maternal/paternal age, conditions like fragile X, genetic, prenatal infection
what is the triad of symptoms for ASD
social interaction (delay in smile/lack of eye contact), communication (lack of non verbal communication and delay in speech) and restricted and repetitive interests
Tx for ASD
-support family
-ABA (applied behavioural analysis)
-special schooling / preschool programme
-control environment
-melatonin for sleep
-SALT
-respite care
screening questionnaire for ASD
GARS
what gives a poor prognosis of ASD
IQ < 50, no communicative speech by age 5
examples of inattention in ADHD
easily distracted, loses things, hard to organise
examples of impulsivity in ADHD
hard to wait their turn, often interrupts others
when can drug therapy be used for ADHD
age 5 and above
MOA of methylphenidate
dopamine and NA reuptake inhibitor
screening questionnaire for ADHD
conners and strengths and difficulties
RF for refeeding syndrome
lost 15% of body weight, alcohol abuse, had little to eat for 6 days
iron OD is common in children as it is found in many multivitamins, what are the stages:
1) 0-6 hours –> GI symptoms
2) GI symptoms ay then resolve before getting worse again –> coagulopathy
at what age do febrile seizures occur
6 months to 6 years (most common around 12-18 months)
RF of febrile seizures
family Hx, fever >40, winter
simple vs complex seizures
simple - less than 15 minutes, post ictal less than one hour and only one in a 24 hour period
complex - longer than 15 minutes, prolonged post octal state and more than one seizure in 24 hours
when is assessment by paeds needed for complex seizures
if it is the first febrile seizure, if they are recurrent or if they are complex
emergency Mx of anaphylaxis
1) lay pt flat
2) IM adrenaline (repeat after 5 mins)
3) oxygen
4) apply monitoring - ECG, BP, pulse oximetry
ALWAYS ADMIT CHILDREN DUE TO POTENTIAL OF A BIPHASIC REACTION
-give fluids at 10ml/kg
what management is done after the initial anaphylaxis
-occur after Tx
-normally do a mast cell tryptase within 6 hours
-refer to allergy clinic
causes for hypoglycaemia
starvation, metabolic (glycogen storage disorder), insulinoma, hepatitis, poisoning
when do paeds need a CT head after head injury
-any suspicion of NAI
-GCS < 15 2 hr after injury or < 14 at presentation
-any laceration over 5 cm
-seizure
-focial neurological deficit
VOMITING IS NOT PART OF THIS
what parameters can score on a PEWS
-resp rate
-resp distress
-oxygen requirement
-heart rate
-level of consciousness
-child and family concern
what does decorticate mean
bilateral flexing to pain
what does decerebrate mean
bilateral extension to pain
RF for erbs palsy
gestational diabetes, macrosomia, mothers with pelvic abnormality
RF for klumpkes palsy (C7/C8/T1)
abducted arm in childhood
signs of klumpkes palsy
claw hand
why is dehydration more common in children
they have higher metabolic rates, cannot communicate thirst and have a greater water requirement
RF of dehydration in children
LBW, <6 months, poor oral intake, vomit > twice in 24 hours, diarrhoea > 5
signs of clinical dehydration
reduced urine output, sunken eyes, dry mucous membranes and reduced skin turgor, may be tachycardic
BUT
-normal BP, normal pulses, normal CRT
signs of clinical shock
hypotension! cold extremities! pale/ mottled skin!
what is the best way to assess dehydration in paeds
through weight loss
mild (>5%)
moderate (5-9%)
severe/shock (10% or more)
if there is no evidence of clinical dehydration, what is the MX
-continue BF
-encourage oral intake but discourage carbonate juice
-assess rehydration risk
what is the Mx for signs of clinical dehydration
ORS over 4 hours - replace 50ml/kg
-continue breast feeding
what fluid is used for maintenance in paeds (IF OVER 28 DAYS)
0.9% NaCl and 5% dextrose
what fluid is used for neonates
10% dextrose !!!!
how much fluid is boluses in shock
10ml/kg of 0.9% NaCl
what can rapid correction of hypernatraemia cause
cerebral oedema
what can rapid correction of hyponatraemia cause
central pontine myelinolysis
what is the most sensitive sign of shock
change in mental state
what is a nitrogen washout test
if a baby has low O2, give them 100% O2 for 10 minutes and then take an ABG. If the PaO2 is <15kPa then this indicates a CYANOTIC CONGENTIAL HEART DISEASE!!! not a resp cause
how are mitochondrial diseases inherited?
spread from the mum only!
so mum gives it to all her children
when it reaches a male there is an abrupt stop
causes for neonatal hypothyroidism
prader willi and hypothyroidism
mx of viral wheeze
1) inhaled SABA
2) oral montelukast or ICS
for multi trigger wheeze trial ICS or montelukast for 4-8 weeks
how long is US the firstline Ix for DDOH
until child is 4.5 months old
5 signs of sepsis in neonate
1) resp distress 2) apnoea 3) tachycardia 4) jaundice 5) poor feeding 6) vomiting
Ix for sepsis in neonate
1) blood cultures
2) CRP and FBC can be misleading in neonate
3) urine culture
4) LP
5) cxr
what causes spina bifida
failure of the vertebral arches to close
Mx of PKU
low protein diet and tyrosine replacement
-need to avoid aspartate too as this is converted into phenylalanine in body
-tyrosine replacement as phenylalanine –> tyrosine in the body
