Neonatology Flashcards
Where is surfactant produced and what is its purpose?
Fluid produced by type II pneumocytes, reduces surface tension.
Not produced until 24-34 weeks gestation.
Keeps alveoli inflated, maximises surface area so increases compliance, reducing force needed to expand alveoli.
What are the cardio-respiratory changes at birth?
Adrenaline and cortisol released in response to birth, stimulating respiratory effort.
During first breaths - alveoli expand decreasing pulmonary vascular resistance.
This causes a fall in pressure in right atrium so left atrial pressure now greater and foramen ovale closes.
Increased blood oxygenation leads to drop in PGs so ductus arterioles shuts. Ductus venosus shuts because umbilical cord has been clamped.
What can occur in extended hypoxia?
Hypoxia occurs as contraction place placenta under stress, unable to carry out normal gas exchange.
Leads to anaerobic respiration, and fatal bradycardia.
Reduced consciousness, drop in respiratory effort.
Hypoxic ischaemic encephalopathy, could lead to cerebral palsy.
What are other key issues in neonatal resus?
Large surface area to weight ratio, so cold easily.
Born wet, so loose heat rapidly.
Born through meconium
What are the principles of neonatal resuscitation?
Warm baby; vigorous drying, heat lamp, plastic bag
APGAR score
Stimulate breathing
Inflation breaths - two cycles of five breaths
Chest compression if HR remains under 60 - 3:1
IV drugs and intubation
Possible HIE - active cooling
What is the APGAR score?
Appearance:
0 blue/pale, 1 bit blue, 2 pink
Pulse:
0 absent, 1 <100, 2 >100
Grimmace:
0 none, 1 little, 2 good
Activity:
0 floppy, 1 flexed, 2 active
Respiration:
0 absent, 1 slow/irregular, 2 strong/crying
What is the purpose of delayed cord clamping?
Provides time for fetal blood still in the placenta to reach the circulation of the baby - placental transfusion.
Leads to improved Hb stores, iron stores, BP and reduction in intraventricular haemorrhage and NEC.
Only negative effect is increase risk of neonatal jaundice.
If requires resuscitation, priority will be with resuscitations than cord clamping.
What care is provided immediately after birth?
Skin to skin Cord clamping Keeping baby dry and warm Vitamin K Label baby Measure weight and length
What is the purpose of Vit K injections?
Babies have a deficiency of Vit K when born.
IM injection given into thigh, key in clotting, prevents bleeding; intracranial, umbilical stump, GI bleeding.
What is the Guthrie test?
Blood spot screen heel prick
Screening card needs 4 separate drops, screens for 9 congenital conditions
Taken on day 5 (birth is 0)
Sickle cell Cystic fibrosis Congenital hypothyroidism Phenylketonuria Medium chain acyl CoA dehydrogenase deficiency Maple syrup urine disease Isovaleric acidaemia Glutaric aciduria type 1 Homocystin
Takes 6-8 weeks to come back
When is the NIPE completed?
Within first 72 hours after birth, and then repeated at 6-8 weeks by GP.
What are some important questions to ask before NIPE?
Has baby passed meconium
Baby feeding ok
FH of any congenital eye, heart or hip problems?
Pregnancy details, birth, breech presentation, abnormalities on antenatal scans
How are pre ductal and post ductal saturations measured?
Before the ductus arterioles closes within 1-3 days of birth.
Pre-ductal before the duct taken from right hand - receives blood from right subclavian from brachiocephalic in aorta before ductus arteriosus, and post ductal in either foot from descending aorta
What are we looking for on general appearance in the NIPE?
Colour - pink is good
Tone
Cry
What are we looking for in the head in the NIPE?
General appearance - size, shape, caput succedaneum, cephalohaematoma, injury
Circumference - occipital frontal circumference OCP
Anterior and posterior fontanelles, overlapping sutures common
Ears - skin tags, low set, asymmetry
Eyes - slight squints normal, epicanthic folds ?Down’s, purulent discharge
Check red reflex
Absent with congenital cataracts and retinoblastoma
Mouth - cleft lip, tongue tie, check suckling reflex, check palate
What are we looking for in the shoulders and arms in the NIPE?
Asymmetry - clavicle fracture
Movements - Erb’s palsy
Brachial and radial pulses
Palmar creases - single crease ?Down’s
Digits - number, straight or curved - clinodactyly
Sats probe on right wrist for pre ductal reading
What are we looking for in the chest in the NIPE?
Oxygen saturations Observe breathing Stridor, work of breathing Heart sounds, murmurs, rate Breath sounds, air entry
Auscultate lungs, heart
What are we looking for in the abdomen in the NIPE?
Observe shape
Concave - diaphragmatic hernia with abdominal contents in the chest
Umbilical stump - look for discharge, infection, hernia
Palpate for organomegaly, hernias, masses
Inspect and palpate
What are we looking for in the genitals in the NIPE?
Observe for sex, ambiguity, abnormalities
Palpate testes and scrotum, check present, descended, hernias or hydroceles
Inspect penis for hypospadias, epispadias, urination
Inspect anus to check patent
Ask about meconium
Inspect labia check not fused
Inspect clitorus, check for any vaginal discharge
What are we looking for in the legs in the NIPE?
Observe legs and hips for equal movements, skin creases, tone, talipes
Barlow’s and Ortolanis
Count the toes
What are we looking for in the back in the NIPE?
Inspect and palpate spine
Look for curvature
Spina bifida
Pilonidal sinus
What reflexes are tested in the NIPE?
Moro - when rapidly tipped back, arms and legs extend
Suckling - finger in mouth
Rooting - tickle cheek, turns towards the stimulus
Grasp - place finger in palm
Stepping - held upright, feet touch surface to make stepping motion
What are some common skin findings in the NIPE?
Haemangiomas Port wine stains Mongolian blue spot Cradle cap Desquamation Erythema toxic Milia - tiny white cysts Acne Naevus simplex - stork bite Moles Transient pustular melanosis
What is caput succedaneum?
Diffuse subcutaneous fluid collection, crosses suture lines
Caused by pressure on presenting part of head during delivery, resolves in first few days
What is a cephalhaematoma?
Subperiosteal haemorrhage
Bound by the periosteum so does not cross sutures
More common in instrumental delivery
May cause jaundice; monitor bilirubin
What is a subgaleal haemorrhage?
Occurs between aponeurosis of scalp and periosteum
Forms large fluctuant collection which crosses suture lines
Rare but life threatening blood loss
What is craniosynostonosis?
One or more of fibrous sutures prematurely fuses
Changes growth pattern of skull
Can result in raised intracranial pressure and damage to intracranial structures
Surgical intervention needed
What might a tense or sunken fontanelle indicate?
Tense bulging - raised ICP e.g. hydrocephalus
Sunken - dehydration
What is a cystic hygroma?
Congenital lymphatic lesion
Typically in left posterior triangle of the neck
Are benign but need surgery
What is caput succedaneum?
Fluid collects on the scalp, outside the periosteum
Caused by pressure to particular area of scalp - during traumatic, prolonged or instrumental delivery.
Crosses suture lines
Resolves in few days
What is a cephalohaematoma?
Collection of blood between skull and periosteum due to traumatic delivery
Does not cross suture lines
Risk of anaemia and jaundice
What is Erb’s palsy?
Injury to C5/C6 in brachial plexus
Associated with shoulder dystocia, traumatic or instrumental delivery, large birth weight.
Leads to weakness of shoulder abduction, external rotation, arm flexion, finger extension - waiters tip.
Function normally returns spontaneously within a few months.
Why might a fractured clavicle occur during birth and how does it present?
Shoulder dystocia, traumatic or instrumental delivery, large birth weight.
Noticable lack of arm movement
Asymmetry of movement in affected arm
Asymmetry of shoulders with affected shoulder lower than the normal shoulder
Pain and distress on movement of the arm
Conservative tx - immobilisation of the affected arm.
What common organisms can cause neonatal sepsis?
Group B strep - does not cause any problems for mother, but transferred in vagina - prophylactic antibiotics during labour
E Coli
Listeria
Klebsiella
Staph aureus
What are the risk factors for neonatal sepsis?
Vaginal GBS colonisation GBS in previous baby Maternal sepsis Chorioamnionitis Fever >38 Prematurity - less than 37 wks Early PROM Prolonged rupture of membranes
What are the clinical features of neonatal sepsis?
Non-specific Fever Reduced tone and activity Poor feeding Respiratory distress or apnoea Vomiting Tachycardia/bradycardia Hypoxia Jaundice within 24 hours Seizures Hypoglycaemia
What are the red flags for neonatal sepsis?
Confirmed or suspected sepsis in the mother
Signs of shock
Seizures
Term baby needing mechanical ventilation
Resp distress >4 hrs from birth
Presumed sepsis in another baby in a multiple pregnancy
What is the management of neonatal sepsis?
One risk factor or clinical features - monitor for 12 hrs
If two - start antibiotics
If red flag - start antibiotics
Start abx within 1 hr of decision
Blood cultures taken before abx, with baseline FBC, CRP
Perform LP if infection strongly suspected or features of meningitis
Benzylpenicillin or gentamicin
Check CRP at 24 hours
Blood cultures at 36 hours
If negative, consider stopping abx, check CRP at 5 days if still on treatment
Then consider stopping abx if clinically well, LP and BCs are negative at 5 days
What is it important to ask in a history to investigate neonatal sepsis?
Pregnancy:
Any concerns with growth, maternal illness, previous invasive infection
Labour and delivery:
duration of membrane rupture, fever during labour, GBS prophylaxis
Birth:
gestational age, weight, APGAR scores, any abnormalities on the NIPE
Since birth any feeding problems, passed urine and meconium, any interventions, any features of sepsis
What neurological features are indicative of neonatal sepsis?
Irritability, seizures, bulging fontanelle
Consider meningitis
What are some of the differentials of neonatal sepsis?
Congenital infections: TORCH Toxoplasmosis Other - syphilis, varicella, HIV Rubella Cytomegalovirus Herpes simplex virus
Respiratory distress syndrome Transient tachypnoea of the newborn Necrotising enterocolitis Congenital pneumonia Congenital heart disease HDN Metabolic diseases - galactosaemia
What specific antibiotics are required for specific symptoms in neonatal sepsis?
Flucloxacillin if late onset
Amoxicillin and cefotaxime IV if meningitis suspected
Metronidazole for NEC
Antifungal e.g. amphotericin B for fungal sepsis
Add aciclovir if HSV suspected
What are some of the complications of neonatal sepsis?
Poor cognitive development Visual or hearing deficits Cerebral palsy Bronchopulmonary dysplasia Death
What is the physiology behind jaundice?
RBCs broken down into bilirubin - unconjugated circulates bound to albumin, and some is free - can cross blood brain barrier.
UGT converts unconjugated to conjugated - cannot cross blood brain barrier, metabolised and excreted in urine and faeces.
What is the process of normal physiological jaundice?
Unconjugated bilirubin, presents on second or third day of life.
Due to shorter lifespan of neonatal RBCs, immature liver at birth, high concentration of beta glucuronidase which converts conjugated back to unconjugated.
Why are some neonates more prone to jaundice?
Preterm babies - higher bilirubin levels.
Breastfed babies - experience more marked and prolonged jaundice
Babies with significant bruising or cephalohaematoma - can occur following difficult deliveries
What are some pathological causes of unconjugated jaundice?
Haemolytic:
HDN, hereditary spherocytosis, G6PD def
Endocrine or metabolic causes:
Gilbert’s syndrome - reduced ability to conjugate bilirubin due to reduced UGT activity
Crigler-Najjar syndrome - no UGT produce by liver, poor prognosis, severe jaundice
Congenital hypothyroidism
Galactosaemia and other inborn errors of metabolism
What are causes of pathological conjugated jaundice?
Biliary atresia
Neonatal hepatitis - due to CMV, hep B, rubella, HSV
Galactosaemia, or other inborn errors of metabolism
What is biliary atresia?
Congenital inflammatory disease of unknown cause
Leads to complete obliteration of the extra-hepatic bile ducts after birth
If not treated, can lead to liver cirrhosis and death
Presents with conjugated jaundice, pale stools, dark urine.
What is the management of biliary atresia?
Liver USS helpful
Percutaneous biopsy gold standard
Kasai procedure - treatment with portoenterostomy or liver transplantation
What are some of the risk factors for significant hyperbilirubinaemia requiring treatment?
Gestational age <38 weeks
Previous sibling with neonatal jaundice requiring phototherapy
Mother’s intention to breastfeed exclusively
Visible jaundice in first 24 hours of life
What other important factors should be asked about in the history for neonatal jaundice?
Family history - inherited diseases, previous sibling
Pregnancy history - congenital infections, diabetes, maternal drugs e.g. sulphonamides
Labour and delivery history - birth trauma
Feeding history - breast-feeding, formula history, intake - poor intake, infrequent stooling increases enterohepatic circulation of bilirubin
What are signs of definite pathological jaundice?
Jaundice in the first 24 hours of life, and conjugated jaundice
What is seen on clinical examination in neonatal jaundice?
Naked, examined in bright light
Most obvious in sclerae and gums, skin can be pressed revealing jaundice in blanched skin
Look for signs of unwell
Inspect nappy for stools and urine - pale chalky stools, dark urine
What are the investigations for neonatal jaundice?
Transcutaneous bilirubinometry - bedside test evaluates light absorption through skin over forehead
Serum bilirubin - babies jaundiced within 24 hrs, gestational age <35, or monitoring bilirubin after starting treatment
What investigations are needed for babies who require treatment for jaundice?
Blood packed cell volume - assess degree of anaemia
Blood group of mother and baby - incompatibility, HDN
Direct antiglobulin test aka Coomb’s - HDN, if negative hereditary spherocytosis
FBC and blood film
G6PD level
Blood, urine, CSF if any signs of infection
Liver ultrasound or percutaneous biopsy - biliary atresia
Genetic testing - Gilbert’s or Crigler Najjar
Urinary reducing substances - galactosaemia
What is the management of neonatal jaundice?
Phototherapy - placed under blue green light, converts neurotoxic unconjugated bilirubin to isomer called lumirubin which can be excreted
Exchange transfusion - swap blood with donor blood
For high levels of bilirubin
What are the complications of neonatal jaundice?
Bilirubin encephalopathy - kernicterus
Unconjugated bilirubin can cross the blood-brain barrier, accumulates in nuclei, basal ganglia, hippocampus, cerebellum; is neurotoxic.
How does kernicterus present?
Lethargy
Hypotonia
Poor suck reflex
Then progresses to hypertonia Opisthotonos - spasm of muscles causing back arching Fever Seizures High pitched cry
Early damage can be reversible but if prolonged;
cerebral palsy
sensorineural hearing loss
cognitive impairment
What is HIE?
Hypoxic ischaemic encephalopathy
Hypoxia during birth
When can HIE be suspected?
Perinatal or intrapartum hypoxia Acidosis pH < 7 on umbilical artery blood gas Poor APGAR scores Features of mild, mod or severe HIE Evidence of multi organ failure
What are the causes of HIE?
Anything that leads to asphyxia e.g.
maternal shock
intrapartum haemorrhage
prolapsed cord - causing compression during birth
nuchal cord - cord wrapped around neck of the baby
What is the Sarnat staging?
Staging for HIE grades
Mild - poor feeding, generally irritability, hyper alert, resolves within 24 hours, normal prognosis
Mod - poor feeding, lethargic, hypotonic, seizures, can take weeks to resolve, up to 40% develop cerebral palsy
Severe - reduced consciousness, apnoeas, flaccid, reduced or absent reflexes, 50% mortality
What is the management of HIE?
Supportive care Acid base balance Treatment of seizures Optimal ventilation Therapeutic hypothermia
What occurs in therapeutic hypothermia?
Actively cooling core temperature to 33-34
Continued for 72 hours, then warmed to normal over 6 hours
Reduces inflammation and neurone loss after injury
Reduces risk of cerebral palsy, developmental delay, learning disability, blindness, death
What is the definition of prematurity?
Extreme - under 28 weeks
Very preterm - 28-32 weeks
Mod-late - 32-37 weeks
What is associated with prematurity?
Social deprivation Alcohol, smoking, drugs Overweight or underweight mother Maternal co-morbidities Twins Personal or FH of prematurity
What management can be given before birth for likely premature birth?
For a history of preterm birth or cervical length less than 25mm before 24 weeks:
Prophylactic vaginal progesterone to discourage labour
Prophylactic cervical cerclage
Tocolysis with nifedipine
Maternal corticosteroids
IV mag sulphate
Delayed cord clamping or cord milking
What is the pathophysiology of respiratory distress syndrome?
Inadequate surfactant leads to high surface tension
Leads to atelectasis - lung collapse, inadequate gas exchange, results in hypoxia, hypercapnia and resp distress.
What is the management of respiratory distress syndrome?
Antenatal steroids e.g. dexamethasone given to mothers with suspected or confirmed preterm birth to increase surfactant.
Intubation, ventilation
Endotracheal surfactant - delivered via endotracheal tube
CPAP
Supplementary oxygen
What are the short term complications of RDS?
Pneumothorax Infection Apnoea Intraventricular haemorrhage Pulmonary haemorrhage Necrotising haemorrhage
What are the long term complications of RDS?
Chronic lung disease of prematurity
Retinopathy of prematurity
Neurological, hearing and visual impairment
What is retinopathy of prematurity?
Affects preterm and LBW babies, typically before 32 weeks gestation.
Abnormal development of blood vessels in retina can lead to scarring, retinal detachment, blindness.
What is the pathophysiology of retinopathy of prematurity?
Retinal blood vessel development is from 16 weeks to 37-40 weeks.
Vessel formation stimulated by hypoxia, normal condition in the retina during pregnancy.
Pre-term babies exposed to higher oxygen conc, plus supplementary oxygen
When this is then removed - can continue growth but responds with neovascularisation and scar tissue.
Abnormal blood vessels regress, retina left without blood supply, may cause retinal detachment.
What screening is advised for ROP?
Babies born before 32 weeks or under 1.5kg should be screened by ophthalmologist:
30-31 weeks gestational age, in babies born before 27 weeks
4-5 weeks if born after 27 wks
Happens at least every 2 weeks, can cease once retinal vessels enter zone 3.
What is the treatment for ROP?
Target areas of retina to stop new blood vessels developing
Transpupillary laser photocoagulation to halt and reverse neorevascularisation
Cryotherapy
Injections of intraviteral VEGF inhibitors
Surgery for retinal detachment
What is apnoea of prematurity?
Apnoea common in premature neonates, decreases with increased gestational age
Breathing stops spontaneously for more than 20 seconds or shorter periods with oxygen desats and bradycardia
What is the cause of apnoea?
Due to immaturity of the ANS Usually sign of developing illness e.g. Infection Anaemia Airway obstruction CNS pathology e.g. seizures or haemorrhage GORD Neonatal abstinence syndrome
What is the management of apnoea of prematurity?
Apnoea monitors
Tactile stimulation
Intravenous caffeine
What is NEC?
Necrotising enterocolitis
Part of the bowel becomes necrotic
Death of bowel tissue can lead to bowel perforation, peritonitis and shock
What are some of the risk factors for NEC?
Very low birth weight or very premature Formula feeds - less common in babies fed by breast milk RDS, assisted ventilation Sepsis Patient ductus arteriosus Other congenital heart disease
What is the presentation of NEC?
Intolerance to feeds Vomiting, green bile Generally unwell Distended tender abdomen Absent bowel sounds Blood in stool
If perforation, there will be signs of peritonitis and shock, baby will be severely unwell
What are the investigations for NEC?
FBC - thrombocytopenia, neutropenia CRP - inflammation Cap blood gas Blood culture Abdominal x-ray - supine
What are the x-ray findings in NEC?
Dilated loops of bowel
Bowel wall oedema - thickened bowel walls
Pneumatosis intestinalis - gas in bowel wall
Pneumoperitoneum - free gas in peritoneal cavity, indicates perforation
Gas in portal veins
What is the management of NEC?
NBM, IV fluids Total parenteral nutrition Antibiotics NG tube to drain fluid and gas Surgical emergency
What are the complications of NEC?
Perforation and peritonitis Sepsis Death Strictures Abscess formation Recurrence Long term stoma Short bowel syndrome after surgery
What is neonatal abstinence syndrome?
Withdrawal symptoms that happens in neonates of mothers that used substances in pregnancy
What are substances that can cause neonatal abstinence syndrome?
Opiates Methadone Benzodiazepines Cocaine Amphetamines Nicotine or cannabis Alcohol SSRI antidepressants
What are the signs and symptoms of neonatal abstinence syndrome?
CNS: Irritability Increased tone Unsettled High pitched cry Tremors Seizures
Vasomotor and resp:
Yawning, sweating
Unstable temp, pyrexia
Tachypnoea
Metabolic and GI:
Poor feeding, regurg
Hypoglycaemia
Loose stoles
What is the management of NAS?
NAS chart for at least 3 days/48 hrs for SSRIs
Urine sample to test for substances
Oral morphine sulphate for opiate withdrawal
Oral phenobarbitone for non-opiate withdrawal
Test for Hep B,C HIV
Safeguarding, safety net
Support
What is seen in metal alcohol syndrome?
Microcephaly Thin upper lip Smooth flat philtrum Short palpebral fissure - short horizontal distance from one side to other Learning disability Behavioural difficulties Hearing and vision problems Cerebral palsy
What are the features of congenital rubella syndrome?
Due to maternal infection with rubella, highest risk in first 3 months
Congenital cataracts
Congenital heart disease - PDA and pulmonary stenosis
Learning disability
Hearing loss
What is seen in congenital varicella syndrome?
Can cause pneumonitis, hepatitis and encephalitis in the mother
Fetal varicella syndrome
Severe neonatal varicella infection if mum infected around delivery
If mum not immune requires IV varicella immunoglobulins with 10 days of exposure
Congenital varicella:
Fetal growth restriction
Microcephaly, hydrocephalus, learning disabilities
Scars, significant skin changes on dermatomes
Limb hypoplasia - underdeveloped
Cataracts and inflammation
What is seen in congenital CMV?
Fetal growth restriction Microcephaly Hearing loss Vision loss Learning disability Seizures
What is the triad of congenital toxoplasmosis?
Intracranial calcification
Hydrocephalus
Chorioretinitis
What are the risk factors for SIDS?
Prematurity
Low birth weight
Smoking during pregnancy
Male baby
What can be done to minimise the risk of SIDS?
Put baby on back when not directly supervised Keep head uncovered Place feet at foot of bed Keep cot clear of toys Maintain comfortable room temp Avoid smoking Avoid handling baby after smoking Avoid co-sleeping, avoid alcohol, drugs, smoking, sleeping tablets, deep sleepers
Why are preterm infants so vulnerable to hypothermia?
Large surface area relative to their mass
Greater heat loss than heat generation
Skin is thin and heat permeable, transepidermal water loss
Little sub cut fat for insulation
Often nursed naked, cannot conserve heat by curling up or generate by shivering
What are common problems in preterm infants following discharge?
Poor growth
Pneumonia, wheezing, asthma
Bronchiolitis from RSV - respiratory syncytial virus
Bronchopulmonary dysplasia
GORD
Complex nutritional and GI disorders following NEC or GI surgery
Inguinal hernias
What is the most likely cause of jaundice starting <24 hrs of age?
Haemolytic disorders - rhesus or ABO incompatibility, G6PD deficiency, spherocytosis
What are the causes of jaundice at 24 hrs - 2 weeks of age?
Physiological jaundice Breast milk jaundice Infection e.g. UTI Haemolysis Bruising Polycythaemia
What are the causes of jaundice at >2 weeks?
Unconjugated - physiological, breast milk, infection, hypothyroid, haemolytic anaemia
Conjugated - >25umol/L
Bile duct obstruction, neonatal hepatitis
What is meconium aspiration?
Passed in preterm infants in response to fatal hypoxia
Asphyxiated so start to gasp and aspirate meconium before delivery - results in obstruction and pneumonitis
What is seen in a CXR in an infant with respiratory distress syndrome?
Bilateral pneumothoraces
What is PPH?
Persistent pulmonary hypertension of the newborn
Associated with birth asphyxia, meconium aspiration, sepsis or RDS
High pulmonary vascular resistance - right to left shunt
Cyanosis
ECHO ensures does not have heart disease
Require mechanical ventilation
What are causes of neonatal seizures?
Hypoxic ischaemic encephalopathy Cerebral infarction Septicaemia Metabolic - hypo/hyper Intracranial haemorrhage Cerebral malformations Drug withdrawal Congenital infection Kernicterus
What is the cause of cleft lip?
Failure of fusion of the frontonasal and maxillary processes
What is the cause of cleft palate?
Failure of fusion of the palatine processes and the nasal septum
What is oesophageal atresia?
Usually associated with tracheo-oesophageal fistula
Associated with polyhydramnios
If suspected, insert feeding tube and check with x-ray
What can be the causes of small bowel obstruction?
Atresia or stenosis of duodenum, seen in Down's Atresia or stenosis of jejunum or ileum Malrotation with volvulus Meconium ileus Meconium plug
What are the causes of large bowel obstruction?
Hirschsprung disease - absence of myenteric plexus - will not pass meconium within 48 hrs of birth
Rectal atresia
Bile stained vomiting is from intestinal obstruction until proved otherwise
What is exomphalos?
Abdominal contents protrude through the umbilical ring, with a transparent sac formed by amniotic membrane and peritoneum
What is gastroschisis?
Bowel protrudes through defect in anterior abdominal wall
Adjacent to umbilicus
No covering sac
Greater risk of dehydration and protein loss
What is the management of a sudden unexpected death of an infant?
Initiate resuscitation unless inappropriate
Care of parents
Baby pronounced dead - detailed clinical exam, aspiration, blood toxicology, chromosomes if dysmorphic, blood culture, LP, urine
Break bad news, parents offered to see and hold baby
Home visit within 24 hours
Post mortem
What is the management of cleft lip and cleft palate?
Cleft lip repaired earlier than cleft palate
From first week of life to 3 months
Cleft palate usually between 6-12 months of age
