neonatology Flashcards

Question

what is physiological jaundice

Answer 1

mild yellowing of skin and sclera from 2 – 7 days of age. This usually resolves completely by 10 days increased destruction of RBCs as the foetal HB is broken down. THis releases bilirubin into the blood and the immature liver is unable to conjugate and excrete it rapidly enough

Answer 2

increased production of bilirubin ``` Haemolytic disease of the newborn rhesus and ABO incompatibility Haemorrhage Intraventricular haemorrhage Cephalo-haematoma Polycythaemia Sepsis and disseminated intravascular coagulation G6PD deficiency ``` ``` decreased clearance of bilirubin Prematurity Breast milk jaundice Neonatal cholestasis Extrahepatic biliary atresia hypothyroid and hypopituitary Gilbert syndrome ```

Answer 3

components of breast milk inhibit the ability of the liver to process the bilirubin.

Answer 4

cause of haemolysis (red blood cells breaking down) and jaundice in the neonate. It is caused by incompatibility between the rhesus antigens on the surface of the red blood cells of the mother and fetus.

Answer 5

When a woman that is rhesus D negative (does not have the rhesus D antigen) becomes pregnant, we have to consider the possibility that her child will be rhesus D positive (has the rhesus D antigen). It is likely at some point in the pregnancy the blood from the baby will find a way into her bloodstream. When this happens, the baby’s red blood cells display the rhesus D antigen. The mother’s immune system will recognise this rhesus D antigen as foreign and produce antibodies to the rhesus D antigen. The mother has then become sensitised to rhesus D antigens. If that fetus is rhesus positive, these antibodies attach themselves to the red blood cells of the fetus and causes the immune system of the fetus to attack their own red blood cells. This leads to haemolysis, causing anaemia and high bilirubin levels. This leads to a condition called haemolytic disease of the newborn.

Answer 6

More than 14 days in full term babies More than 21 days in premature babies Structural – Biliary atresia / choledochal cyst / Alagille's syndrome Infective – CMV / EBV / Hep-B / Bacterial / Toxoplasmosis Metabolic – Galactosaemia / Alpha-1-antitrypsin deficiency / Storage disease Genetic – CF / Trisomy 21 / Trisomy 18 Neoplastic – Hepatoblastoma / Neuroblastoma Toxic – Drug induced Endocrine – Hypothyroidism / Panhypopituitarism Vascular – Budd-Chiari / Congestive heart failure

Answer 7

- FBC +Blood film for polycythaemia or anaemia - Total serum bilirubin/LFTs - Blood type testing of mother and baby for ABO or rhesus incompatibility - coagulation study - deranged indicates poor liver function - Paternal blood group and rhesus status - Peripheral blood smear - misshapen blood cells could indicate RBC disorder - Reticulocyte count - for presence of haemolysis - Direct Coombs Test (direct antiglobulin test) for haemolysis - Thyroid function, particularly for hypothyroid - Blood and urine cultures if infection is suspected. - G6PD levels ->deficiency - Galactosaemia screen - TORCH fro infection

Answer 8

observe for 24 hours total bilirubin levels are monitored and plotted on treatment threshold charts. These charts are specific for the gestational age of the baby at birth. The age of the baby is plotted on the x-axis and the total bilirubin level on the y-axis. If the total bilirubin reaches the threshold on the chart, they need to be commenced on treatment to lower their bilirubin level. - > Phototherapy is usually adequate to correct neonatal jaundice. Extremely high levels may require an exchange - > transfusion. Exchange transfusions involve removing blood from the neonate and replacing it with donor blood.

Answer 9

unconjugated bilirubin into isomers that can be excreted in the bile and urine without requiring conjugation in the liver. Once phototherapy is complete, a rebound bilirubin should be measured 12 – 18 hours after stopping to ensure the levels do not rise about the treatment threshold again. considerations - distance of light of baby - eye protection - remove clothes off baby except nappy - temperature - bilirubin levels

Answer 10

type of brain damage caused by excessive bilirubin levels. It is the main reason we treat neonatal jaundice to keep bilirubin levels below certain thresholds. Bilirubin can cross the blood-brain barrier. Excessive bilirubin causes direct damage to the central nervous system. Kernicterus presents with a less responsive, floppy, drowsy baby with poor feeding. The damage to the nervous system is permeant, causing cerebral palsy, learning disability and deafness

Answer 11

hypoxia during birth. hypoxia during the perinatal or intrapartum period, acidosis (pH < 7) on the umbilical artery blood gas, poor Apgar scores, features of mild, moderate or severe HIE (see below) or evidence of multi organ failure.

Answer 12

- Maternal shock - Intrapartum haemorrhage - Prolapsed cord, causing compression of the cord during birth - Nuchal cord, where the cord is wrapped around the neck of the baby

Answer 13

sarnat staging Mild Poor feeding, generally irritability and hyper-alert Resolves within 24 hours Normal prognosis Moderate Poor feeding, lethargic, hypotonic and seizures Can take weeks to resolve Up to 40% develop cerebral palsy Severe Reduced consciousness, apnoeas, flaccid and reduced or absent reflexes Up to 50% mortality Up to 90% develop cerebral palsy

Answer 14

oordinated by specialists in neonatology, on the neonatal unit. This involves supportive care with neonatal resuscitation and ongoing optimal ventilation, circulatory support, nutrition, acid base balance and treatment of seizures. Therapeutic hypothermia is an option in certain circumstances to help protect the brain from hypoxic injury. Children will need to be followed up by a paediatrician and the multidisciplinary team to assess their development and support any lasting disability.

Answer 15

involves actively cooling the core temperature of the baby according to a strict protocol. The baby is transferred to neonatal ICU and actively cooled using cooling blankets and a cooling hat. The temperature is carefully monitored with a target of between 33 and 34°C, measured using a rectal probe. This is continued for 72 hours, after which the baby is gradually warmed to a normal temperature over 6 hours. The intention of therapeutic hypothermia is to reduce the inflammation and neurone loss after the acute hypoxic injury. It reduces the risk of cerebral palsy, developmental delay, learning disability, blindness and death.

Answer 16

development milestones extension of independent as adults or not

Answer 17

long term neuro underdevelopment lower gestation = greater risk of cerebal palsy

Answer 18

rehospitalisation rate increased CLD or BPD may require home oxygen - chronic lung disease at 36 weeks gestation if u need oxygen til 36 weeks - wheezing more common with CLD - FORD - GI disorders esp necrotising enterocolitis increased risk of COPD at later stages

Answer 19

all children at less than 30 weeks at 2 years

Answer 20

robertsonian translocation | abnormal division

Answer 21

Palpebral fissure (up slanting), Round face Occipital + nasal flattening, Brushfield spots (pigmented spots on iris)/Brachycephaly Low-set small ears Epicanthic folds Mouth open + protruding tongue Strabismus (squint)/Sandal gap deformity/Single palmar (Simian) crease

Answer 22

automated otoacoustic emission automate auditory brainstem response

Answer 23

first 4-5 weeks of life automated otoacoustic emission abnormal reasons your baby was unsettled when the test was done there was background noise your baby has fluid or a temporary blockage in their ear abnormal automate auditory brainstem response abnormal hearing specialist

Answer 24

glue ear – a build-up of fluid in the middle ear, which is common in young children infections that develop in the womb or at birth, such as rubella or cytomegalovirus, which can cause progressive hearing loss inherited conditions, such as otosclerosis, which stop the ears or nerves from working properly damage to the cochlear or auditory nerves (which transmit hearing signals to the brain); this could be caused by a severe head injury, exposure to loud noise or head surgery, for example being starved of oxygen at birth (birth asphyxia) illnesses such as meningitis and encephalitis (which both involve swelling in the brain)

Answer 25

``` web neck short stature wide spaced nipples underdeveloped ovaries -> amenorrhoea infertility bicuspid valve coarction of aorta acute otitis media ``` monosomy - one normal sex chromosome

Answer 26

``` mastitis ductal candida cracked breast engorgement baby not latching ```

Answer 27

``` mastitis ductal candida cracked nipples breast engorgement baby not latching blocked duct attachment issues ```

Answer 28

colic GORD Gastroenteritis lactose intolerance

Answer 29

``` minimise the separation of mum and baby loose stools dehydration retinal damage bronze baby syndrome ```

Answer 30

conjugated bilirubin as it does not lead to kernicterus

Answer 31

accumulates in CNS grey matter irreversible neurological damage - bilirubin neurotoxic ``` early signs - severe jaundice hypotonia poor sucking and feeding - absent startle reflex - high pitched cry - bulging fontanelles ``` ``` neurological features sensory hearing loss intellectual disability speech difficulties seizures movement disorder muscle rigidity ```

Answer 32

``` cosleeping low birth weight smoking tangles breathing obstruction ```

Answer 33

always place your baby on their back to sleep place your baby in the "feet to foot" position – with their feet touching the end of the cot, Moses basket, or pram keep your baby's head uncovered – their blanket should be tucked in no higher than their shoulders let your baby sleep in a cot or Moses basket in the same room as you for the first 6 months use a mattress that's firm, flat, waterproof and in good condition breastfeed your baby,

Answer 34

<2.6mmol/L it is common within the first 24 hours <1 VERY LOW so administer IV 10% dextrose infusion

Answer 35

``` preterm birth (< 37 weeks) maternal diabetes mellitus IUGR hypothermia neonatal sepsis inborn errors of metabolism nesidioblastosis Beckwith-Wiedemann syndrome ```

Answer 36

``` may be asymptomatic autonomic (hypoglycaemia → changes in neural sympathetic discharge) - 'jitteriness' - irritable - tachypnoea - pallor neuroglycopenic - poor - feeding/sucking - weak cry - drowsy - hypotonia - seizures other features may include - apnoea - hypothermia ```

Answer 37

``` asymptomatic encourage normal feeding (breast or bottle) monitor blood glucose symptomatic or very low blood glucose admit to the neonatal unit intravenous infusion of 10% dextrose ```

Answer 38

Birth: Dry the baby, remove any wet towels and cover and start the clock or note the time. Within 30 seconds: Assess tone, breathing and heart rate. Within 60 seconds: If gasping or not breathing - open the airway and give 5 inflation breaths Re-assess: If no increase in heart rate look for chest movement If chest not moving: Recheck head position, consider 2-person airway control and other airway manoeuvres, repeat inflation breaths and look for a response. If no increase in heart rate look for chest movement When the chest is moving: If heart rate is not detectable or slow (< 60 min-1) - start chest compressions with 3 compressions to each breath. Reassess heart rate every 30 seconds. If heart rate is not detectable or slow (<60 beats per minute) consider venous access and drugs

Answer 39

Perinatal asphyxia. Polycythaemia. Respiratory distress. Congenital anomalies (myelomeningocele, congenital heart disease). Cow's milk protein-induced enterocolitis and glucose-6-phosphate dehydrogenase deficiency have been mooted as possible pathophysiological mechanisms.

Answer 40

first two weeks of life - Abdominal distension with increasing gastric aspirates. - Visible intestinal loops. - Altered stool pattern. Bloody mucoid stool and bilious vomiting. - Decreased bowel sounds with erythema of the abdomen. Palpable abdominal mass or ascites. Associated features are bradycardia, lethargy, shock, apnoea, respiratory distress, temperature instability.

Answer 41

prematuring low birth weight

Answer 42

``` Sepsis. Haemolytic disease of the newborn. Swallowed maternal blood. Volvulus/malrotation. Intussusception. Pseudomembranous colitis. Stress ulcer. ``` abdominal xray dilated bowel loops bowel oedema poneumoatosis intestinalis - intramural gas portal venous gas rigler's sign air inside and outside of bowel football signs - outline falciform ligaments pneumoperitoneum perforation

Answer 43

Nil by mouth to rest the bowel. Nasogastric or orogastric tube to decompress the bowel with low intermittent orogastric suction. Intravenous (IV) fluids, total parenteral nutrition (TPN) and IV antibiotics for 10-14 days: Ampicillin/gentamicin or cefotaxime. Plus metronidazole or clindamycin. perforation - laparotomy

Answer 44

``` Perforation. Acquired short bowel syndrome (following surgery). Stoma-related complications.[18] DIC. Sepsis and shock. Intestinal strictures (~30%). Enterocolic fistulae. Abscess formation. Recurrent NEC (rare) ```

Answer 45

TOF in mum can cause polyhydraminos

Answer 46

``` Frothy, white bubbles in the mouth Coughing or choking when feeding Vomiting Blue color of the skin (cyanosis), especially when the baby is feeding Difficulty breathing Very round, full abdomen ```

Answer 47

``` Frothy, white bubbles in the mouth Coughing or choking when feeding Vomiting Blue color of the skin (cyanosis), especially when the baby is feeding Difficulty breathing Very round, full abdomen ```

Answer 48

NG tube curls up on xray air Demonstration of the nasogastric tube curled in the proximal oesophagus in a child where the passage of the tube has been unsuccessful is usually sufficient for diagnosis. The proximal oesophageal stump may be distended with air (types A and C ). The presence of air in the stomach and bowel in the setting of oesophageal atresia implies that there is a distal fistula. Often the lungs demonstrate areas of consolidation/atelectasis due to recurrent aspiration.

Answer 49

``` ripogle drain out oesophagus anti laparoscopic thoracotomy ICU discharge once feeding and gaining weight ```

Answer 50

affects within 28 days of life EOS - <72 hrs of birth LOS between 7-28 days of life causes group b strep Ecoli LOS - coagulase-negative staphylococcal species such as Staphylococcus epidermidis, Gram-negative bacteria such as Pseudomonas aeruginosa, Klebsiella and Enterobacter, and fungal species Staphylococcus aureus Enterococcus Listeria monocytogenes Viruses including herpes simplex and enterovirus - Mother who has had a previous baby with GBS infection, who has current GBS colonisation from prenatal screening, current bacteruria, intrapartum temperature ≥38ºC, membrane rupture ≥18 hours, or current infection throughout pregnancy - Premature (<37 weeks): approximately 85% of neonatal sepsis cases are in premature neonates - Low birth weight (<2.5kg) - Evidence of maternal chorioamnionitis

Answer 51

``` 1. Respiratory distress (85%) Grunting Nasal flaring Use of accessory respiratory muscles Tachypnoea ``` 2. Tachycardia 3. Apnoea 4. Apparent change in mental status/lethargy 5. Jaundice 6. Seizures: if cause of sepsis is meningitis 7. Poor/reduced feeding 8. Abdominal distention 9. Vomiting 10. Temperature

Answer 52

blood culture - 2 if possible - FBC - abnormal neutrophils - CRP - Blood gases - metabolci acidosis - urine microscopy culture and sensitivity - raised leukocytes, positive culture, haematuria, proteinuria - LP -> MAYBE Mx <1m gentamicin + amoxicillin + cefotaxime 1-3m amoxicillin + ceftriaxone 3m ceftriaxone - CRP should be re measure 18-24hrs after presentation - antibiotics can be ceased at 48 hours in neonates who have CRP of <10 mg/L and a negative blood culture at presentation and at 48 hours Other important management factors to consider include: - Maintaining adequate oxygenation status - Maintaining normal fluid and electrolyte status: severely ill neonates may require volume and/or vasopressor support. Body weight needs to be measured daily for accurate assessment of fluid status - Prevention and/or management of hypoglycaemia - Prevention and/or management of metabolic acidosis

Answer 53

deficient in vit k Vit K orally or IM RFs - breast milk - maternal use of antiepileptics

Answer 54

Other risk factors for SDLD include - male sex - diabetic mothers - Caesarean section - second born of premature twins tachypnoea, intercostal recession, expiratory grunting and cyanosis ground-glass' appearance with an indistinct heart border Management 1. prevention during pregnancy: maternal corticosteroids to induce fetal lung maturation 2. CPAP oxygen assisted ventilation exogenous surfactant given via endotracheal tube

Answer 55

commonest cause of respiratory distress in the newborn period. It is caused by delayed resorption of fluid in the lungs Csection Ix Chest x-ray may show hyperinflation of the lungs and fluid in the horizontal fissure Supplementary oxygen may be required to maintain oxygen saturations. Transient tachypnoea of the newborn usually settles within 1-2 days

Answer 56

A rare benign lung lesion made up of abnormal lung tissue arising from an error in lung development that does not function properly but continues to grow. Also called congenital pulmonary airway malformation. CCAMs develop antenatally and would usually thus be visible on antenatal scans. They vary in size and are either solid or cystic

Answer 57

General: is the child alert? A high pitched cry could indicate he is unwell. Any rashes? Face: any signs of dysmorphia? Head: size may be affected by congenital infections. Trauma such as cephalohaematoma can lead to jaundice Abdominal: hepatomegaly? Splenomegaly?

Answer 58

``` American-Indian descent Maternal diabetes Decreased gestational age Family history of neonatal jaundice Breastfeeding ```

Answer 59

early onset jaundice <24 hours gestational age <35 weeks if encephalopathy is suspected

Answer 60

idiopathic destructive inflammatory process. The fibrotic remains can be seen at the porta hepatis. Mx kapasi portoenterostomy