Neonates Flashcards
Why is jaundice seen in over 50% of newborns
Increase in breakdown of RBC as high Hb at birth
Red blood cells have shorter lifespan in neonates
Hepatic metabolism less efficient
What is kernicterus
Bilirubin encephalopathy as free unconjugated bilirubin can cross the BBB
How can kernicterus present
Moderate cases
- lethargy and poor feeding
Severe cases
- irritability
- increased muscle tone (oplsthotonos)
- seizures and comas
What is oplsthonos
When babies lie with arched back
What are long term effects of kernicterus
Choreoathetoid cerebral palsy
Sensorineural deafness
Learning disabilities
Where does jaundice typically present in a newborn
The head and then spreads downwards with increasing severity
Cephalocaudal
Referral guidelines for neonates with jaundice
If first showed signs within 24 hrs of life then admit to neonatal or paeds unit within 2 hours
If over 24 hours admit within 6 hours if
- first appeared at more than 7 days
- very unwell
- gestational age less than 35 weeks
- prolonged jaundice
- issues about weight
- pale stools and dark urine
If neither of these
- get transcutaneous bilirubin level with 6 hours if not refer to hospital for bilirubin level in 6 hours
Investigations in secondary care for jaundiced baby
FBC and blood film
Blood group
DAT
LFTs
G6PD levels
Cultures of urine/blood to look for cause of sepsis
What determines prolonged jaundice in neonates
Gestational age of 37 or more = 14 days
Gestational age of less than 37= 21 days
Difference in solubility between unconjugated and conjugated bilirubin
Unconjugated- fat
Conjugated- water
How does phototherapy work on jaundice
Converts uBR to lumirubin and photobilirubin but DOES NOT WORK on Conjugated bilirubin
What is problem with transcutaneous bilirubin measurements
Only shows levels of unconjugated- if urgent then do blood reading which will show split between conjugated and unconjugated
Causes of jaundice in first 24 hours of life
Infection
ABO or Rh incompatibility
G6PD or HS
Gilberts
Cirgler-Najjar
Differences between Rhesus incompatibility and ABO
Rhesus negative mums produce ABs against Rhesus positive baby- normally does not affect first pregnancy only subsequent
ABO occurs in type O mums with naturally occuring Anti-A/B ABS- can occur in any pregnancy
Rhesus not very common but extremely serious
ABO more common but reduced morbidity/mortality
Rfx for haemolytic disease of the newborn
Chorionic villous sampling
Amniocentesis
Vaginal delivery
Antenatal haemorrhage
How to diagnose haemolytic disease of the newborn
Coombs test- will show positive indirect antiglobulin test showing IgG in maternal blood
Antibodies in ABO incompatibility
Anti-A haemolysin IgG- more common
Anti-B haemolysin IgG
What triggers gilberts to cause neonatal jaundice
Normally infection
What is Criger-Najjar syndrome
Results in a complete dysfunction of the gene encoding UDP-Glucuronyl transferase
Difference between Criger-Najjar syndrome and gilberts
CN results in a complete dysfunction of the gene encoding UDP-Glucuronyl transferase whereas gilberts get some activity
In CN the hyperbilirubinaemia is massive
Treatment options for acute bilirubin encephalopathy
Immediate exchange transfusion
Phototherapy
Hydration
IVIG
Folic acid after to prevent anaemia
Things to tell parent if baby undergoing phototherapy
Not harmful but eyes will be covered with blood samples taken regularly so know when to stop
Breastfeeding every 3 hours
Need to measure bilirubin after to check for rebound hyperbilirubinaemia
Options for treating neonatal jaundice
Phototherapy
Exchange transfusion
Thresholds for determining when to
Common causes of jaundice neonatal jaundice
Physiological
Breast milk jaundice
Sepsis
Feeding difficulty
What is biliary atresia
Progressive fibrosis and obliteration of extra and intra hepatic ducts
Symptoms of biliary atresia
Pale stools
Dark urine
Mild jaundice
DONT GET VOMITING
Examination finding of biliary atresia
Hepatosplenomegaly
Mild jaundice
Can get cardiac murmurs
What are the types of biliary atresia
T1- common bile duct
T2- cystic dict
T3- fulla tresia where over 90%
Problems of biliary atresia
Progress to chronic liver failure in 2 years and then HCC
Faltering growth despite normal birth weight
Investigations for biliary atresia
USS
Lfts- elevated GGT
High conjugated CBr
TIBIDA SCAN
ERCP and biopsy
US finding of biliary atresia
Triangular chord sign
Gold standard for biliary atresia
TIBIDA isoptope scan also known as scintiligraphy
Confirmatory test for biliary atresia
ERCP and biopsy
Management of biliary atresia
1st line -Kasai hepatoportoenterostomy- involves ligating the fibrous ducts above the join with the duodenum and joining an end of the duodenum directly to the porta hepatis of the liver
If fails need liver transplant
Complication management
F Fat-soluble vitamins (levels monitored)
U Ursodeoxycholic acid promotes bile flow
P Prophylactic ABx to prevent cholangitis (co-trimoxazol
Causes of jaundice between 24 hours and 2 weeks
Physiological
Breastfeeding difficulty
Breastmilk jaundice
Metabolic- gilberts, HS etc
Biliary atresia
Congenital hypothyroidism
Infection
What causes breastfeeding jaundice
Where babies do not receive enough milk there is increased enterohepatic cycling of bilirubin
What is congenital hypothyroidism and why serious
A lack of thyroid hormones from birth
Lack of growth and neurological defects
Aetiology of congenital hypothyroidism
In order of most common
Thyroid gland defects (missing etc) (not inherited)
Thyroid hormone metabolism (TSH unresponsive) (inherited)
Transient
Hypothalamic/pituitary dysfunction (tumours, ischaemia etc)
What can cause transient hypothyroidism
Seen in neonates
Maternal anti-thyroid medication like carbimazole, PTU
Maternal ABs from hashimotos
Presentation of congenital hypothyroidism
Feeding difficulties
Lethargy
Constipation
JAUNDICE
Large fontanelles
Niche- umbilical hernia, coarse features (flattened nasal bridge), macroglossia, thin hair
Investigations for congenital hypothyroidism
High TSH and low T4
Measure thyroid autoantibodies ± US or radionucleotide scan
Management of congenital hypothyroidism
Thyroxine hormone replaced with levothyroxine OD, titrate dose to TFTs + regular monitoring
Monitor growth, milestones, development
Management of primary hypothyroidism in children
Thyroxine hormone replaced with levothyroxine OD, titrate dose to TFTs + regular monitoring
Monitor growth, milestones, development
Most common cause of acquired childhood hypothyroidism
Hashimotos
Rfx for hashimotos hypothyroidism
Down’s syndrome, Turner’s syndrome
Female
Risk of graves mums giving birth
1-2% can be born hyperthyroid due to circulating TSHr-Abs which can cross placenta
Signs of foetal hyperthyroidism
High CTG trace
Foetal goitre on USS
Signs of neonatal hyperthyroidism
Irritability
Tachycardia
Diarrhoea
Exopathalmos
HF
Medical managment of hyperthyroidism
Carbimazole or PTU
Can consider beta blockers if symptomatic
Other management is surgery or radioactive treatment
When does anterior fontanelle shut
9-18 mths
What does absent red reflex suggest in newborn check
Retinoblastoma
Could be congenital cataracts
Normal newborn head circumfrence
23-35 cm
Highest of 3 measurements
What is a cephalhematoma versus caput
Cephalhematoma is a bleed under the epicranial aponeuris and restricted to suture lines
Caput succundem- swelling under the skin/subcut tissue- crosses suture lines
What is concerning about cephalematoma
Cause may be skull fracture
White spots on the face of newborn
Milia
Management of cephalematoma
Monitor jaundice
What causes a bleed in sclera of eye- newborn
Subconjunctival haemorrhage
What is the barlow and ortolani manoever
Dislocate femur out of hip joint- check if weakness
How is hydrocele of newborn managed
Normally self limiting within a year however if not need surgery
What syndrome is port and winerash associated with
Sturg-weber
Signs of resp distress in children
Nasal flaring
Subcostal recession
Tracheal indenting
What are categories of preterm infant
Preterm under 37
Near term 34-36
Very preterm 29-33
Extremely preterm under 29
What causes TTN
Lungs still full of amniotic fluid
Transient tachypnoea of the fluid
What causes RDS
Lack of endogenous surfactant
Decreases surface tension and prevents collapse of alveoli
Rfx for RDS
Maternal DM
Preterm
Hypothermia- deactivates surfactant
Elective C section
Any cause of hypoxia
What is protective for RDS
Pre-eclampsia
Recurrent threatened preterm labour (as able to give steroids)
Symptoms for RDS
Tachypnoea
Grunting
Cyanosis
Head bobbing
Chest wall recession
CXR of RDS
Ground glass appearance with bronchogram
Risk of trophic feeds
Spontaneous pneumothorax
These are small volumes of mik given to stimulate bowels not for nutrition
What increases risk of IVH in kids
CSF produced in choroid plexus which are very fragile and vascular. As mature get more supported with connective tissue- until this is risk of rupture into
How are IVH graded
1- bleeding only in germinal matrix
2- bleeding can occur into ventricles
3- grade 2 but blocked ventricles and theyre now dilated
4- ventricles so dilated it compresses surrounding venous
When is post haemorrhagic ventricular dilation a problem
Grade 3 and 4 IVH
Rfs for NEC
LBW
Preterm
PDA as reduces blood flow
Symptoms of NEC
Quiet
Feeding intolerance
Bilious vomiting or in NG tube
Bloody stools
If really bad- distension,
AXR of NEC
Pneumoperitoneum
Treatment of NEC
Stop enteral feeds and medications
- give TPN if feeds stopped for over 24 hours
- if confirmed NEC stop feeds for 1 weeks
NG tube on free drain
Abx- cefotaxime and vancomycin
Resp support if abdo distended
Fluids- may need ionotropes
Surgery if perforation
Complications of NEC
Perforation
Recurrent strictures
Neuro-maldevelopment
Short gut syndrome if feeding
What is chronic lung disease
Ongoing oxygen needed for 28 days
Rfx of CLD
Ventilation injury
Infection
RDS
Fluid overload
Complications of CLD and how managed
Very susceptible to future infection
- vaccinate against flu at 6 months
- vacciante against RSV
Wheezy for first 3 months
What is ROP
Retinopathy of prematurity- refractive errors or squints
Risks for ROP
Low birth weight
preterm
Hyperoxaemia
Management of ROP
Treated for up to 2 years
MDT approach
Photocogulation
What antibiotics given in RDS
Benzylpenicillin and gentamicin
What is main risk factor for TTN
C-section or preterm
Treatment for TTN
Oxygen if needed
Treatment for CLD
Manage oxygen therapy- wean off if necessarty or give what necessary
Caffeine citrate
Nitric oxide if pulmonary hypoplasia or pulmonary HTN
CXR finding of CLD
Widespread opacification
Can be atelectasis, multicystic appearance, emphysema or pulmonary scarring
Management of NEC
Resp support and potential cardio
Stop enteral feeding and medications- switch to parenteral
NG tube left on free drain
Abx with good cover- cefotaxime and vancomycin
Surgery if needed
What is used to diagnose vesicoureteric reflex
Micturating cytourethrogram