Neonates Flashcards
When is the newborn baby check completed
Completed within the first 72 hours of life
Usually between 6-24 hours
Repeated by the GP at 6-8 weeks
What is the purpose of the newborn baby check
It is designed to recognise serious congenital abnormalities
Particularly developmental dysplasia of the hip, congenital heart disease, congenital cataracts and cryptorchidism.
Also alleviates parental concerns and promotes good health
What is considered a term baby
Term is anything between 37 and 42 week
Due date is 40 weeks
What is the earliest viabilty for a foetus
Around 23 weeks
What is the normal RR and breathing pattern for a neonate
RR 40-60
Periodic breathing, they breath fast and then slow
What is considered tachypnoea in a neonate
Breathing consistently over 60 bpm
How is CPAP used in neonates
CPAP keeps the lungs from collapsing
Baby still has to breath out against the pressure but this stops a complete alveolar collapse
Grunting in a neonate can be a sign of what
Respiratory distress
Hypoglycaemia
Sepsis
Cold
What is considered an apnoea in a neonate
Cessation of breathing for more than 20 seconds
Why should you avoid ventilating neonates
It can cause barotrauma to the lungs - leads to chest problems in later life
Can cause a pneumothorax
How does respiratory distress appear on a CXR
Lung fields are hazy - ground glass appearance
Due to collapsed alveoli - don’t have air in them so they appear white on CXR
How do you manage RDS
Anyone below 29 weeks is intubated and given prophylactic surfactant
The artificial surfactant comes from pigs lungs and is administered directly into the lungs via ET tube
How are chest drains inserted in babies
Put a needle into the cavity and then pass a wire into the space
The catheter can then be passed over the wire and the wire removed.
What is chronic lung disease/ bronchopulmonary dysplasia
A consequence of RDS
Diagnosed if the child requires O2 beyond 36 weeks corrected gestation and has CXR changes
How can you prevent bronchiolitis in vulnerable neonates
metapneumovirus on top of RSV
Give a monoclonal antibody (IgG) to RSV to children who are going home on oxygen due to CLD
Get monthly injections for first 2 years of life to vulnerable babies
Why are C-section babies more prone to transient tachypnoea of the newborn
Babies should reabsorb fluid through the stress of labour and then the first breath causes more absorption
C-section babies are more prone to TTN as they haven’t gone through labour
Neonates are obligate nasal breathers - true or false
True
When do babies develop the suck refelx
At 32 weeks
Therefore babies born before this will not be able to feed properly and require parenteral nutrition
How do you progress feeding in preterm babies
Babies born before 32 weeks will not have a developed suck reflex
The will need parenteral nutrition
Then progress to NG followed by oral feeds
Give them a dummy while NG feeding so they associate sucking with a feed
Why can you not give oral tetracycline to a neonate
Causes yellowing of the teeth in children
How do you manage neonatal acne
It should go away on its own
What causes neonatal acne
Caused by mum’s hormones
More common in boys
What causes physiological jaundice of the newborn
Caused by the breakdown of red blood cells
Baby’s have a high RBC count as they need to optimise O2 transport
Once born and breathing they don’t need as many so lots break down
Also need to switch to adult haemoglobin so cells with foetal type also need broken down
Jaundice within 24hrs is likely pathological - true or false
True
When does physiological jaundice of the newborn present
At least 24hrs after birth
Any earlier and it is pathological
At which point would you need to investigate ‘physiological jaundice’
If the baby is still jaundiced at 2 weeks old
List potential causes of pathological jaundice in a neonate
Could be cause by a haemolytic reaction - ABO or rhesus incompatibility
What is biliary atresia
A congenital abnormality where there is no link between liver and gut
It causes backflow of bile and liver damage
Causes conjugated jaundice
How do you manage biliary atresia
Requires an operation within 45-60 days to create a path for bile
What signs suggest conjugated jaundice
Pale stools and dark urine
How does phototherapy for neonatal jaundice work
It is just a specific wavelength of blue light, it is not UV
It causes photoisomerization - makes the bilirubin water soluble so that it can be excreted in the urine
Used for both pathological and physiological jaundice
Why must babies be under a heat shield whilst getting phototherapy
They have to be naked to absorb the light but it is important they stay warm too
Babies are bad at preserving body heat
How do you determine if neonatal jaundice needs treatment
There is a bili chart which determines if the SBR requires treatment
It is corrected for gestation
What is the risk of high bilirubin levels in babies
Risk of kernicterus
This is when unconjugated bilirubin crosses the BBB and deposits in the brain - can cause encephalopathy and a type of CP with movement disorder
What causes the waiter’s tip sign in babies
Called Erb’s palsy
Caused by brachial plexus injury (C5/6), often due to shoulder dystocia
How do you manage Erb’s palsy in children
Most get better often with physio
How do you treat necrotising enterocolitis
Stop feeding the baby and give triple antibiotic therapy
How does necrotising enterocolitis appear on AXR
Has a soap bubble appearance
Presents with free gas, gas in the bowel wall and dilated bowel loops
May lead to perforation
What causes necrotising enterocolitis
Ischemic bowel - leads to widespread necrosis in the small and large intestine
May be due to premature bowel, bacterial overgrowth and poor blood supply
It is a problem of prematurity
Babies temperature on admission is directly related to their mortality and morbidity - true or false
True
The colder they are on admission, the sicker they are
What is involved in the APGAR score
Activity, pulse, grimace, appearance, respiration
Scale is subjective
Max score of 10 (8 and above is good though)
Recorded at 1 min 5 min and 10 min
How do you prevent heat loss in premature babies
Prem babies are put in plastic bags to prevent heat loss by evaporation
It also protects their immature skin
Should also put a hat on them
GCS is not applicable in neonates - true or false
True
They cannot follow commands or
speak so the scores don’t apply
Tend to just use AVPU
What would you look for in the D and E sections of a ABCDE exam of a newborn
Pupil size, reactivity and fundi if possible
Posture (decorticate or decerebrate which indicate brain damage)
Neck stiffness
Fontanelles - bulging indicates raised ICP
Rashes - purpura, petechiae, bruising
Fever
List reversible causes of LOC in children
Hypoxia
Hypoglycaemia
Hypothermia
Hypotension/hypertension
Infection - meningitis/encephalitis Ingestion Trauma - time critical (TC) Metabolic conditions - may get very sick with simple illnesses Raised ICP - TC Stroke - TC
What is the purpose of steroids given in premature births
Helps the lungs develop before baby is born - encourages surfactant production
2 doses are given to mum - last dose given at least 12 hours before birth
What is the purpose of magnesium sulphate given in premature births
Reduces neurodevelopmental impairment (e.g. CP)
Given to mum within 24 hours of delivering the baby
Given as an 8 hour infusion
When does surfactant start being produced
Around 24 weeks
However, even babies up to 34 weeks may be surfactant deficient - not enough produced
Steroids will always prevent RDS in neonates - true or false
False
Steroids promote production but may not completely prevent RDS
Babies may still be surfactant deficient
What is oscillation
One of the highest type of breathing support given to neonates - via ventilator
Causes rapid breaths that get CO2 out of lungs
Given to babies who are acidotic
Why is vitamin K given to newborns
Helps with clotting and reduced haemorrhage risk
Why is caffeine citrate given to neonates
To help with respiratory rate, prevents apnoeas and serve as neuroprotection
What are the 1st line antibiotics for neonates
Benpen and gent
Most premature babies are given prophylactic antibiotics - true or false
True
Prematurity is a risk factor for sepsis
Premature babies are given multivitamins - true or false
True
Their vitamin stores are not yet built up
Only given once fully enterally fed
Children up to 5 should be given multivitamins - new Scottish guidelines
Where can a neonate pick up a candida infection
Birth canal or breast
What is transient neonatal pustular melanosis
A brown, scaly, hyperpigmented macular rash seen in newborns
Most strawberry haemangiomas will go away on their own - true or false
True
Most go away in a few months
If extensive or causing facial distortion they can be removed
Why is it important to document the presence of a mongolian blue spot on newborn exam
May be confused with NAI if missed on initial exam
Looks like a bruise
What is a mongolian blue spot
A type of birth mark - blue in appearance
Most common in south American and south African children
What is a stork bite
A reddish mark seen on the head of a newborn
Very common sign
Goes away in a couple of weeks
When do the fontanelles usually close
Anterior font closed by 18 months
Posterior closes by 6 weeks
What is cephalhaematoma
Bleeding under periosteum on the parietal bones - benign hemorrhage
Caused by minor birth trauma
Leads to a mishapen head in newborns - swells
Does not cross the midline
What is cephalhaematoma
Bleeding under periosteum on the parietal bones - benign hemorrhage
Caused by minor birth trauma
Leads to a mishapen head in newborns - swells
Does not cross the midline
What is caput succedaneum
Swelling in a newborns scalp -c an make head cone shaped
Caused by fluid collecting as the baby descends - more common in prolonged labors
Typically goes away in around 48 hours
When might you see a conjunctival haemorrhage in a newborn
Haemorrhage often seen following difficult delivery – due to pressure
Will go away in a few day
Why is it important to check for the red reflex in a newborn
Picks up congenital cataracts and retinoblastoma
If cataract not picked up in first 6 weeks they don’t form important neural connection which leads to blindness
A family history of hearing loss increases a child’s risk of hearing issues - true or false
True
What is choanal atresia
Congenital abnormality where the bony part of back of nose does not allow air exchange
Watch for colour change when mouth closes
What ear features should you look for in the newborn exam
Tags/pits Position - e.g. low set Unusual shape Papillomas Hairy ear
All babies should receive a hearing assessment before leaving hospital - true or false
True
Early identification of hearing loss has been demonstrated to prevent many adverse consequences and facilitate language acquisition
Why might a newborn present with breast growth
The breast tissue can be abnomrally enlarged - 3-4cm due to affects of maternal oestrogens
List signs of congestive heart failure in newborns
Heart gallop, tachycardia and abnormal pulses
Hepatomegaly
List the 5 areas of the heart that should be listened to on newborn examination
The Apex …mitral area
Lower left sternal edge at 4th intercostal space - tricuspid area
Left of the sternum in the 2end intercostal space - pulmonary area
Right of the sternum in the 2end intercostal space - aortic area
Midscapular area , posteriorly - coarctation area
Which pulses should be checked in newborns
Brachial, radial and femoral pulses
Should be checked for rate, rhythm and volume
What abnormalities are seen in the tertralogy of fallot
Large ventricular sepal defect
An overriding aorta
Stenosis of pulmonary valve
Right ventricular hypertrophy
It is uncommon to be able to feel the liver and/or spleen in healthy newborn - true or false
False
It is common
How many blood vessels are found in the umbilicus
Should have 2 arteries 1 vein
What should you look for in examination of the umbilicus
Inspect for discharge, redness or edema around base of the cord
Should be translucent. A greenish yellowish colour suggests meconium staining
If a child has ambigious genitalia how do you assign a gender
You DONT
Any infant with ambigious genitalia should not undergo gender assignment until a formal endocrinology evaluation
What is cryptotorchidism
When the testes (one or both) have not descended
What is phimosis
When the foreskin cannot be retracted
What is a vaginal tag
A small appendage or flap on the mucous membranes
It is a common neonatal variation that usually disappears in a few weeks
How do you examine the male genitalia
Determine site of meatus Palpate bilateral testicles Examine for inguinal hernia Look for hypospadias, epispadias, chordae. Observe colour of scrotum
How do you examine the female genitalia
Inspect for size and location of the labia, clitoris, meatus, and vaginal opening
What does abnormal pigmentation/ hairy patches over the lower back suggest
Increases the suspicion that there is an underlying vetebral abnormality
What is spina bifida
A defect in closure of the neural tube - incomplete development of the brain, spinal cord, and/or meninges
It is associated with malformations of the vertebrae & spinal cord
A single palmar crease may be a sign of what
Down’s syndrome
What are the main risk factors for hip dysplasia
Breech presentation
Female gender
Family history
List signs of hip dysplasia which may be seen on newborn exam
Asymmetry of legs
Extension of one or both sides of groin folds or buttock creases
Range of abduction, may reveal subtle instability
Instability test Barlow and Ortalani tests
Which reflexes should be present in newborns
Rooting reflex Glabellar reflex Grasp reflex Neck righting reflex Moro’s reflex
What is considered low birth weight
Low Birth weight: birth weight less than 2500g
Very low birth weight (VLBW): birth weight less than 1500g
Extremely Low Birth weight (ELBW): birth weight less than 1000 g
What is considered small for gestational age
<10th centile in weight expected for gestation
What is considered large for gestational age
> 90th centile in weight expected for gestation
List risk factors for preterm birth
Carrying more than one baby (twins, triplets, or more).
Problems with the uterus or cervix.
Chronic health problems in the mother, such as high blood pressure, diabetes, and clotting disorders.
Certain infections during pregnancy.
Cigarette smoking, alcohol use, or illicit drug use during pregnancy
Should you cut the cord immediately after birth
If the baby is OK and can be kept warm then you should delay cord clamping for at least a minute to allow placental transfusion
How should you position a newborns head to open their airways
Keep head in a neutral position = over extension will block airway due to different anatomy
Instead use a jaw thrust
Can use gentle suction - only if secretions evident
Why are babies bad at regulating their temperatures
Low BMR
Minimal muscular activity
Subcutaneous fat insulation is negligible
High ratio of surface area to body mass
Why are prem babies at increased risk of nutritional compromise
Limited nutrient reserves
Immature metabolic pathways
Increased nutrient demands - lots of associated medical/surgical conditions which increase demand or reduce delivery
What is meant by early onset neonatal sepsis
Sepsis caused by bacteria that is acquired before or during delivery
What is meant by late onset neonatal sepsis
Sepsis caused by an infection which is acquired after delivery - nosocomial or community sources
List some common respiratory complications of prematurity
Respiratory distress syndrome (RDS)
Apnoea of prematurity
Bronchopulmonary dysplasia
What is the primary pathology behind RDS
Surfactant deficiency and structural immaturity of the lungs
What secondary pathological changes occur in RDS
Alveolar damage
Formation of exudate from leaky capillaries
Inflammation
Repair – fibrosis, altered structure
List the clinical features of RDS
Respiratory distress - tachypnoea, grunting, intercostal recessions, nasal flaring, cyanosis
Worsens over minutes to hours
Gradually worsens at 2-4 days then a gradual improvement
What is intraventricular haemorrhage
A type of intracranial haemorrhage that occurs in preterm infants
Begins with bleeding into the germinal matrix.
What are the risk factors for intraventricular haemorrhage
Prematurity
Respiratory distress syndrome - hypoxia, acidosis and hypotension make it more likely to have an unstable cerebral circulation
How does intraventricular haemorrhage present
25-50% are clinically silent
Intermittent deterioration - hypoxia, pallor, hypotension, tachycardia, irritability, apnoea
Some experience a catastrophic deterioration and cardiovascular collapse
What is the most common neonatal surgical emergency
Necrotising enterocolitis
How does necrotising enterocolitis present
Occurs usually after recovering from RDS
Early signs: lethargy and gastric residuals
Bloody stool, temperature instability, apnoea and bradycardia
How does necrotising enterocolitis present
Occurs usually after recovering from RDS
Early signs: lethargy and gastric residuals
Bloody stool, temperature instability, apnoea and bradycardia
When is the newborn screening test carried out
Ideally 5 days after birth
Babies up to their first birthday are eligible for the test, however the test for Cystic Fibrosis must
be done before 8 weeks of age
What is screened for in the heel prick test
Phenylketonuria Cystic Fibrosis Congenital Hypothyroidism Medium-chain Acyl Co-A Dehydrogenase Deficiency (MCADD) Sickle Cell Disorder Maple Syrup Urine Disease (MSUD) Isovaleric Acidaemia (IVA) Glutaric Aciduria Type 1 (GA1) Homocystinuria (HCU)
Mostly enzyme deficiency
