Neonateology Flashcards
What is the most frequent cause of severe early-onset (< 7 days) infection in newborn infants?
Group B streptococcus infection
What is caput succedaneum?
Caput succedaneum (caput) involves fluid (oedema) collecting on the scalp, outside the periosteum.
How does caput present and how is it resolved?
There is usually no, or only mild, discolouration of the skin. It does not require any treatment and will resolve within a few days.
What causes caput?
Caput is caused by pressure to a specific area of the scalp during a traumatic, prolonged or instrumental delivery.
The periosteum is a layer of dense connective tissue that lines the outside of the skull and does not cross the sutures (the gaps in the baby’s skull).
The fluid is outside the periosteum, which means it is able to cross the suture lines.
Fluid (oedema) collecting on the scalp, outside the periosteum.
What is Cephalohaematoma?
A cephalohaematoma is a collection of blood between the skull and the periosteum.
It is caused by damage to blood vessels during a traumatic, prolonged or instrumental delivery.
It can be described as a traumatic subperiosteal haematoma.
Cephalohaematoma vs caput?
In cephalohaematoma, the blood is below the periosteum, therefore the lump does not cross the suture lines of the skull. In caput the blood is above the periosteum so the lump does cross the suture lines.
Additionally, the blood can cause discolouration of the skin in the affected area in cephalohaematoma.
How does cephalohaematoma appear?
Head swelling, localised within suture boundaries, discolouration due to blood
Management of cephalohaematoma?
Usually a cephalohaematoma does not required any intervention and resolves without treatment within a few months.
There is a risk of anaemia and jaundice due to the blood that collects within the haematoma and breaks down, releasing bilirubin. For this reason the baby should be monitored for anaemia, jaundice and resolution of the haematoma.
Potential complication of cephalohaematoma and the subsequent required monitored?
There is a risk of anaemia and jaundice due to the blood that collects within the haematoma and breaks down, releasing bilirubin. For this reason the baby should be monitored for anaemia, jaundice and resolution of the haematoma.
Why might a neonate have facial paralysis?
Delivery can cause damage to the facial nerve.
Facial nerve injury is typically associated with a forceps delivery.
This can result in facial palsy (weakness of the facial nerve on one side).
Management/prognosis of facial paralysis?
Function normally returns spontaneously within a few months.
If function does not return they may required neurosurgical input.
Facial nerve injury in the newborn is most commonly the result of what?
Forceps delivery
Features of Erb’s palsy
Weakness of shoulder abduction and external rotation, arm flexion and finger extension.
This leads to the affected arm having a “waiters tip” appearance:
Internally rotated shoulder
Extended elbow
Flexed wrist facing backwards (pronated)
Lack of movement in the affected arm
What causes Erb;s palsy?
An Erb’s palsy is the result of injury to the C5/C6 nerves in the brachial plexus during birth
What is Erb’s palsy associated with?
It is associated with shoulder dystocia, traumatic or instrumental delivery and large birth weight.
Which nerves are involved in Erb’s palsy?
C5/C6 nerves in the brachial plexus
What might a clavicle fracture during birth be associated with?
The clavicle may be fractured during birth. A fractured clavicle can be associated with shoulder dystocia, traumatic or instrumental delivery and large birth weight.
Presentation of clavicle fracture in the newborn?
A fractured clavicle can be picked up shortly after birth or during the newborn examination with:
Noticeable lack of movement or asymmetry of movement in the affected arm
Asymmetry of the shoulders, with the affected shoulder lower than the normal shoulder
Pain and distress on movement of the arm
A fractured clavicle can be confirmed with ultrasound or x-ray.
Management of clavicle fracture in the newborn?
Management is conservative, occasionally with immobilisation of the affected arm.
It usually heals well.
Potential complication of fractured clavicle in the newborn?
The main complication of a fractured clavicle is injury to the brachial plexus, with a subsequent nerve palsy.
Components of immediate care of the neonate after birth?
Skin to skin
Clamp the umbilical cord
Dry the baby
Keep the baby warm with a hat and blankets
Vitamin K
Label the baby
Measure the weight and length
Why do newborns require vitamin K?
Babies are born with a deficiency of vitamin K.
Vitamin K is an important part of normal blood clotting.
IM injection shortly after birth can have the helpful side effect of stimulating the baby to cry, which helps expand the lungs.
Vitamin K helps to prevent bleeding, particularly intracranial, umbilical stump and gastrointestinal bleeding.
How might vitamin K be delivered to the newborn?
Standard practice is to give all babies an intramuscular injection of vitamin K in the thigh shortly after birth.
Alternatively, vitamin K can be given orally, however this takes longer to act and requires doses at birth, 7 days and 6 weeks.
What is meant by skin to skin contact and what are the benefits?
Skin to skin contact involves putting the baby against the mothers chest immediately after birth. This has several potential benefits:
Helps warm baby
Improves mother and baby interaction
Calms the baby
Improves breast feeding
Normal care after birth following leaving the delivery room?
Initiate breast feeding or bottle feeding as soon as the baby is alert enough
The first bath is usually delayed until this baby is warm and stable. It can wait days without any issues.
Newborn examination within 72 hours
Blood spot test
Newborn hearing test
What conditions are screened for in Blood Spot Screening?
Sickle cell disease
Cystic fibrosis
Congenital hypothyroidism
Phenylketonuria
Medium-chain acyl-CoA dehydrogenase deficiency (MCADD)
Maple syrup urine disease (MSUD)
Isovaleric acidaemia (IVA)
Glutaric aciduria type 1 (GA1)
Homocystin
What is Blood Spot Screening?
This is a screening test for 9 congenital conditions.
It is taken on day 5 (day 8 at the latest) after consent from the parent.
A heel prick is used to provide drops of blood.
The screening card requires four separate drops.
When does blood spot screening need to happen?
Ideally at day 5, by day 8 at the latest
How long does it take for blood spot screening results to come back?
6-8weeks
What is NAS?
Neonatal abstinence syndrome (NAS) refers to the withdrawal symptoms that happens in neonates of mothers that used substances in pregnancy. The symptoms and management is slightly different for each substance used in pregnancy. Mothers should be encouraged and supported with cutting back, and if possible stopping, substances that can affect the pregnancy.
What substances can cause NAS?
Opiates
Methadone
Benzodiazepines
Cocaine
Amphetamines
Nicotine or cannabis
Alcohol
SSRI antidepressants
In NAS, which substances can cause withdrawal symptoms from 3-72 hours following birth?
Most opiates
Diazepam
SSRIs
Alcohol
In NAS, which substances can cause withdrawal symptoms from 24 hours and 21 days following birth?
Most benzodiazepines other than diazepam
Methadone
CNS signs of NAS
Irritability
Increased tone
High pitched cry
Not settling
Tremors
Seizures
Vasomotor and respiratory signs of NAS
Yawning
Sweating
Unstable temperature and pyrexia
Tachypnoea (fast breathing)
Metabolic and GI signs of NAS
Poor feeding
Regurgitation or vomiting
Hypoglycaemia
Loose stools with a sore nappy area
NAS - what additional things should be considered after acute management?
Testing for hepatitis B and C and HIV
Safeguarding and social service involvement
Safety-net advice for readmission if withdrawal signs and symptoms occur
Follow up from paediatrics, social services, health visitors and the GP
Support for the mother to stop using substances
Check the suitability for breastfeeding in mothers with substance use
Management of NAS
Mothers that are known to use substances should have an alert on their notes so that when they give birth the neonate can have extra monitoring and management of NAS.
Babies are kept in hospital with monitoring on a NAS chart for at least 3 days (48 hours for SSRI antidepressants) to monitor for withdrawal symptoms.
A urine sample can be collected from the neonate to test for substances.
The neonate should be supported in a quiet and dim environment with gentle handling and comforting.
Medical treatment options for moderate to severe symptoms are dependent on the substance.
Neonates should be gradually weaned off oral treatment.
SSRI withdrawal does not typically require or benefit from medical treatment.
Medical management of moderate to severe NAS due to opiate withdrawl
Oral morphine sulphate for opiate withdrawal
Medical management of moderate to severe NAS for non-opiate substances
Oral phenobarbitone for non-opiate withdrawal
SSRI withdrawal does not typically require or benefit from medical treatment.
What conditions may arise in the neonate during to events in pregnancy?
Fetal Alcohol Syndrome
Congenital Rubella Syndrome
Congenital Varicella Syndrome
Congenital Cytomegalovirus
Congenital Toxoplasmosis
Congenital Zika Syndrome
Features of fetal alcohol syndrome?
Microcephaly (small head)
Thin upper lip
Smooth flat philtrum (the groove between the nose and upper lip)
Short palpebral fissure (short horizontal distance from one side of the eye and the other)
Learning disability
Behavioural difficulties
Hearing and vision problems
Cerebral palsy
Features of congenital rubella syndrome
Congenital cataracts
Congenital heart disease (PDA and pulmonary stenosis)
Learning disability
Hearing loss
When is the risk of congenital rubella syndrome highest
First trimester
Potential consequences VZV infection in pregnancy
More severe cases in the mother, such as varicella pneumonitis, hepatitis or encephalitis
Fetal varicella syndrome
Severe neonatal varicella infection if mum is infected around delivery
Symptoms congenital varicella syndrome?
Fetal growth restriction
Microcephaly, hydrocephalus and learning disability
Scars and significant skin changes following the dermatomes
Limb hypoplasia (underdeveloped limbs)
Cataracts and inflammation in the eye (chorioretinitis)
Congenital varicella syndrome occurs in around 1% of cases of chickenpox in pregnancy. It occurs when there is infection in which part of pregnancy?
first 28 weeks of gestation.
Congenital cytomegalovirus (CMV) infection symptoms?
Fetal growth restriction
Microcephaly
Hearing loss
Vision loss
Learning disability
Seizures
Classic triad of symptoms Congenital Toxoplasmosis?
Intracranial calcification
Hydrocephalus
Chorioretinitis
When is the risk of congenital toxplasmosis higher?
Infection with the Toxoplasma gondii parasite is usually asymptomatic. It is primarily spread by contamination with faeces from a cat that is a host of the parasite. When infection occurs during pregnancy it can lead to congenital toxoplasmosis. This risk is higher later in the pregnancy
Congenital Zika syndrome features?
Microcephaly
Fetal growth restriction
Other intracranial abnormalities, such as ventriculomegaly and cerebellar atrophy
What issues in early life can result from prematurity (birth before 37 weeks gestation)
Respiratory distress syndrome
Hypothermia
Hypoglycaemia
Poor feeding
Apnoea and bradycardia
Neonatal jaundice
Intraventricular haemorrhage
Retinopathy of prematurity
Necrotising enterocolitis
Immature immune system and infection
Long term affects of prematurity (birth before 37 weeks gestation)
Chronic lung disease of prematurity (CLDP)
Learning and behavioural difficulties
Susceptibility to infections, particularly respiratory tract infections
Hearing and visual impairment
Cerebral palsy
What is SIDS and when does it occur
Sudden infant death syndrome (SIDS) is a sudden unexplained death in an infant. It is sometimes referred to as “cot death”. This usually occurs within the first six months of life.
Risk factors for SIDS
Prematurity
Low birth weight
Smoking during pregnancy
Male baby (only slightly increased risk)
Measures to prevent SIDS?
Put the baby on their back when not directly supervised
Keep their head uncovered
Place their feet at the foot of the bed to prevent them sliding down and under the blanket
Keep the cot clear of lots of toys and blankets
Maintain a comfortable room temperature (16 – 20 ºC)
Avoid smoking. Avoid handling the baby after smoking (smoke stays on clothes).
Avoid co-sleeping, particularly on a sofa or chair
If co-sleeping avoid alcohol, drugs, smoking, sleeping tablets or deep sleepers
Support for parents who have lost a child to SIDS
The lullaby trust is a great charity to help support families affected.
Bereavement services and bereavement counselling should be available for affected families.
What is NEC?
Necrotising enterocolitis (NEC) is a disorder affecting premature neonates, where part of the bowel becomes necrotic.
It is a life threatening emergency.
Death of the bowel tissue can lead to bowel perforation.
Bowel perforation leads to peritonitis and shock.
Risk facotrs for NEC
Very low birth weight or very premature
Formula feeds (it is less common in babies fed by breast milk feeds)
Respiratory distress and assisted ventilation
Sepsis
Patient ductus arteriosus and other congenital heart disease
Presentation of NEC
Intolerance to feeds
Vomiting, particularly with green bile
Generally unwell
Distended, tender abdomen
Absent bowel sounds
Blood in stools
When perforation occurs there will be peritonitis and shock and the neonate will be severely unwell.
Blood tests in NEC
Full blood count for thrombocytopenia and neutropenia
CRP for inflammation
Capillary blood gas will show a metabolic acidosis
Blood culture for sepsis
Investigations for NEC
Abdominal xray is the investigation of choice for diagnosis in the supine position
Bloods (FBC, CRP, blood culture)
CBG
Management of NEC
Neonates with suspected NEC need to be nil by mouth with IV fluids, total parenteral nutrition (TPN) and antibiotics to stabilise them.
A nasogastric tube can be inserted to drain fluid and gas from the stomach and intestines.
NEC is a surgical emergency and requires immediate referral to the neonatal surgical team.
Some neonates will recover with medical treatment. In others, surgery may be required to remove the dead bowel tissue.
Babies may be left with a temporary stoma if significant bowel is removed.
NEC: complications
Perforation and peritonitis
Sepsis
Death
Strictures
Abscess formation
Recurrence
Long term stoma
Short bowel syndrome after surgery
What is apnoea of prematurity?
Apnoea are defined as periods where breathing stops spontaneously for more than 20 seconds, or shorter periods with oxygen desaturation or bradycardia.
Apnoea can occur in neonates of all gestational ages. They are often accompanied by a period of bradycardia.
Apnoea is very common in premature neonates. They occur in almost all babies less than 28 weeks gestation and the incidence decreases with increased gestational age. In term infants apnoea usually indicate underlying pathology.
Causes of apnoea in the neonate
Apnoea occur due to immaturity of the autonomic nervous system that controls respiration and heart rate.
This system is more immature in premature neonates.
Apnoea in the neonate are often a sign of developing illness, such as what?
Infection
Anaemia
Airway obstruction (may be positional)
CNS pathology, such as seizures or haemorrhage
Gastro-oesophageal reflux
Neonatal abstinence syndrome
Management of neonatal apnoea?
Neonatal units attach apnoea monitors to premature babies.
These make a sound when an apnoea is occurring.
Tactile stimulation is used to prompt the baby to restart breathing.
Intravenous caffeine can be used to prevent apnoea and bradycardia in babies with recurrent episodes.
Episodes will settle as as the baby grows and develops.
What is retinopathy of prematurity and why is screening important?
Retinopathy of prematurity is a condition affecting preterm and low birth weight babies.
It typically affects babies born before 32 weeks gestation.
Abnormal development of the blood vessels in the retina can lead to scarring, retinal detachment and blindness.
Treatment can prevent blindness, which is why screening is so important.
Babies born before what gestation are typically affected by retinopathy of prematurity
Babies born before 32 weeks
Appearance of respiratory distress syndrome on CXR
Chest xray shows a “ground-glass” appearance.
