Neonatology Flashcards
When is surfactant produced
24-34 weeks gestation
What are the issues with neonatal hypoxia
Happens during normal labour and delivery
Can lead to fetal bradycardia
If ongoing, can get hypoxic-ischaemic encephalopathy
What are the main principles in neonatal resuscitation
Warm baby
Calculate APGAR score
Stimulate breathing
Inflation breaths
How is the APGAR score calculated
Appearance (colour)
Pulse
Grimace (response to stimulation)
Activity (muscle tone)
Respiration
Calculate at 1, 5, and 10 minutes
How is breathing stimulated during neonatal resuscitation
Dry vigorously with towel
Place head in neutral position
If gasping, check for obstruction
How are inflation breaths delivered in neonatal resuscitation
2 cycles of 5 inflation breaths
30 seconds ventilation breaths
Chest compressions
Why is delayed umbilical cord clamping used
Allows time for blood from cord to go into fetal circulation
Improves: Hb levels, iron stores, blood pressure
Reduces: intraventricular haemorrhage, necrotising enterocolitis
Uncompromised neonates: at least 1 minute
Compromised neonates: clamp when needed and start resuscitation
What conditions are screened for in the newborn heel prick test
On day 5, results in 6-8 weeks
Sickle cell disease
Cystic fibrosis
Congenital hypothyroidism
Phenylketonuria
MCADD
Maple syrup urine disease
Isovaleric acidaemia
Glutaric aciduria type 1
Homocysteine
When does the newborn examination take place
Within 72 hours
At 6-8 weeks (by GP)
What do you need to look for in the general appearance part of the newborn examination
Colour
Tone
Cry
What do you need to look for in the head part of the newborn examination
General appearance (size, shape, dysmorphology, cephalohaematoma)
Head circumference
Sutures
Ears (low set, asymmetry)
Eyes (epicanthic folds in Down’s, discharge in infection)
Red reflex (absent in congenital cataracts and retinoblastoma)
Mouth (cleft lip, tongue tie)
Sucking reflex and cleft palate
What do you need to look for in the shoulders and arms part of the newborn examination
Shoulder asymmetry
Arm movements
Brachial pulses
Radial pulses
Palmar creases
Digits
What do you need to look for in the chest part of the newborn examination
Observe breathing (distress, symmetry, stridor)
Heart sounds
Breath sounds
What do you need to look for in the abdomen part of the newborn examination
Observe for sex
Palpate testes and scrotum (descent, hernias, hydrocele)
Inspect penis (hypospadias, urination)
Inspect anus (check patency)
Ask about meconium
What do you need to look for in the legs part of the newborn examination
Observe legs and hips (equal movements, skin creases, tone, talipes)
Barlow and Ortolani manoeuvres (clunking, clicking, dislocation)
Count toes
What do you need to look for in the back part of the newborn examination
Inspect and palpate spine (curvatures, spina bifida, pilonidal sinus)
What do you need to look for in the reflexes part of the newborn examination
Mono reflex (arms and legs extend when tipped back quickly)
Suckling reflex (when place finger in mouth)
Rooting reflex (turn towards stimulus when tickling cheek)
Grasp reflex (grab finger if placed in palm)
Stepping reflex (make stepping movements when upright and feet touch a surface)
What do you need to look for in the skin findings part of the newborn examination
Haemangiomas
Port wine stains
Mongolian blue spot
Cradle cap
Desquamation
Erythema toxisum
Milia
Nevus simplex
Moles
Transient pustular melanosis
What is caput succedaneum
A birth injury
Oedema of scalp (outside periosteum, able to cross suture lines)
Due to pressure on scalp during long/traumatic/instrumental delivery
Will resolve in a few days
What is caphalohaematoma
A birth injury
Collection of blood between skull and periosteum (does not cross suture lines)
Due to pressure on scalp during long/traumatic/instrumental delivery
Discolouration of skin
Will resolve in a few months
Risk of anaemia and jaundice
What is Erb’s palsy
Injury to C5/C6 in brachial plexus
Associated with: shoulder dystocia, traumatic delivery, high birth weight
Weakness of: shoulder abduction, external rotation, arm flexion, finger extension
Get a waiter’s tip appearance
Function usually returns in a few months
What are clavicle fracture birth injuries
Associated with: shoulder dystocia, traumatic delivery, high birth weight
Picked up during newborn examination (lack of movement, asymmetry, pain)
Confirm via ultrasound or X-ray
Conservative management
Can get brachial plexus nerve palsies
What are the common organisms that cause neonatal sepsis
Group B strep
E coli
Listeria
Klebsiella
Staph aureus
What are the risk factors for neonatal sepsis
Maternal vaginal GBS
GBS in previous baby
Maternal sepsis, chorioamnionitis, or fever > 38
Prematurity
Premature rupture of membranes
Prolonged rupture of membranes
What are the clinical features of neonatal sepsis
Fever
Reduced tone and activity
Poor feeding
Respiratory distress
Vomiting
Tachycardia or bradycardia
Hypoxia
Jaundice within 24 hours
Seizures
Hypoglycaemia
What are the red flags for neonatal sepsis
Confirmed or suspected sepsis in mother
Signs of shock
Seizures
Term baby needed mechanical ventilation
Respiratory distress starting >4 hours after birth
Presumed sepsis in another baby in multiple pregnancy
What is the management for presumed neonatal sepsis
1 risk factor or clinical feature: close monitoring for 12 hours
2+ risk factors or clinical signs: start antibiotics
Any red flags: start antibiotics
Antibiotics: within 1 hour, benzylpenicillin
Consider lumbar puncture
What is the ongoing management for neonatal sepsis
Check CRP at 24 hours
Check blood culture results at 36 hours
Consider stopping antibiotics when: baby clinically well, blood cultures negative, CRP low
What is hypoxic-ischaemic encephalopathy
Occurs in neonates due to hypoxia during birth
Can lead to permanent damage (cerebral palsy)
Causes: maternal shock, intrapartum haemorrhage, prolapsed cord, nuchal cord (cord around neck)
What are the signs of mild hypoxic-ischaemic encephalopathy
Poor feeding
Generally irritable
Hyper-alert
Resolves within 24 hours
What are the signs of moderate hypoxic-ischaemic encephalopathy
Poor feeding
Lethargy
Hypotonia
Seizures
Can take weeks to resolve
40% develop cerebral palsy
What are the signs of severe hypoxic-ischaemic encephalopathy
Reduced consciousness
Apnoea
Flaccid, absent, or reduced reflexes
Up to 50% mortality
90% develop cerebral palsy
What is the management for hypoxic-ischaemic encephalopathy
Supportive care
Therapeutic hypothermia (protects brain from hypoxic injury, cool to 33-36 degrees for 72 hours, warm over 6 hours)
What is neonatal jaundice
Jaundice in babies as they have high concentration of fragile red blood cells and less developed livers
Normal at 2-7 days
Pathological if within 24 hours
Prolonged if > 14 days in term babies (> 21 days in preterm babies)
What are the causes of neonatal jaundice related to increased production of bilirubin
Haemolytic disease of newborn
ABO incompatibility
Haemorrhage
Intraventricular haemorrhage
Cephalo-haematoma
Polycythaemia
Sepsis
DIC
G6PD deficiency
What are the causes of neonatal jaundice related to decreased clearance of bilirubin
Prematurity
Breast milk jaundice
Neonatal cholestasis
Extrahepatic biliary atresia
Endocrine disorders
Gilbert syndrome
What are the investigations for neonatal jaundice
FBC
Blood film
Conjugated bilirubin
Blood type testing
Direct Coombs test (for haemolysis)
Thyroid function tests
Blood culture
Urine culture
G6PD
What is the management for neonatal jaundice
Plot bilirubin levels on treatment threshold chart (specific to gestational age of baby at birth)
Phototherapy (converts unconjugated bilirubin to isomers which can be excreted)
Exchange transfusion
What factors are associated with prematurity
Social deprivation
Smoking
Alcohol
Drugs
Over/underweight mother
Twins
Personal or family history
What is the management for prematurity before/at birth
Tocolysis (nifedipine, suppresses labour)
Maternal corticosteroids (if < 35 weeks)
IV magnesium sulphate (protect baby’s brain, if < 34 weeks)
Delayed cord clamping and cord milking
What are the issues of prematurity in early life
Respiratory distress syndrome
Hypothermia
Hypoglycaemia
Poor feeding
Apnoea
Bradycardia
Neonatal jaundice
Intraventricular haemorrhage
Retinopathy of prematurity
Necrotising enterocolitis
Immature immune system
What are the long term effects of prematurity
Chronic lung disease of prematurity
Learning disability
Susceptibility to infection
Hearing and visual impairment
Cerebral palsy
What is apnoea of prematurity
Breathing stops spontaneously for more than 20 seconds
Often with bradycardia
Very common in neonates born at < 28 weeks
Incidence decreases with increasing gestational age
What are the causes of apnoea of prematurity
Due to immaturity of autonomic nervous system
Often a sign of developing illness (infection, anaemia, airway obstruction, CNS pathology, GOR, neonatal abstinence syndrome)
What is the management for apnoea of prematurity
Attach apnoea monitors
Tactile stimulation (prompt baby to restart breathing)
IV caffeine (stimulate respiratory drive)
Episodes settle as baby grows and develops
What is retinopathy of prematurity
Abnormal development of blood vessels in retina, leading to scarring, retinal detachment, blindness
Retinal blood vessels start developing at 16 weeks (finish at 37 weeks), form under hypoxic conditions
If have hypoxic episode after birth, get production of excessive blood vessels (neovascularisation)
When hypoxic episode ends, blood vessels can regress, causing retinal detachment
When is retinopathy of prematurity screened for
For babies born at < 32 weeks or < 1.5 kg
At 30-31 weeks gestational age for babies born before 27 weeks
At 4-5 weeks of age for babies born after 27 weeks
Monitor every 2 weeks
What is the management for retinopathy of prematurity
Transpupillary laser photocoagulation (halt and reverse neovascularisation)
Cryotherapy
Inject intravitreal VEGF inhibitors
Surgery (for retinal detachment)
What is respiratory distress syndrome
Common in babies born before 32 weeks
Get ground glass appearance on chest X-ray
What is the management for respiratory distress syndrome
Antenatal steroids for mother
Intubation and ventilation
Endotracheal surfactant
CPAP
Oxygen
What are the short term complications of respiratory distress syndrome
Pneumothorax
Infection
Apnoea
Intraventricular haemorrhage
Pulmonary haemorrhage
Necrotising enterocolitis
What are the long term complications of respiratory distress syndrome
Chronic lung disease of prematurity
Retinopathy of prematurity
Neurological impairment
Hearing impairment
Visual impairment
What is necrotising enterocolitis
Part of bowel becomes necrotic in premature neonates
Life threatening emergency
Can get bowel perforation
What are the risk factors for necrotising enterocolitis
Very low birth weight
Very premature
Formula feeding
Respiratory distress or assisted ventilation
Sepsis
Patent ductus arteriosus
How might a patient with necrotising enterocolitis present
Intolerant to feeds
Vomiting with green bile
Generally unwell
Distended, tender abdomen
Absent bowel sounds
Blood in stool
What are the investigations for necrotising enterocolitis
Bloods
Capillary blood gas
Blood cultures
Abdominal X-ray (dilated bowel loops, bowel wall oedema, pneumatosis intestinalis, pneumoperitoneum)
What is the management for necrotising enterocolitis
Nil by mouth
IV fluids
Total parenteral nutrition
Antibiotics
A surgical emergency
What are the complications of necrotising enterocolitis
Perforation and peritonitis
Sepsis
Death
Strictures
Abscess formation
Recurrence
Long term stoma
Short bowel syndrome
What is neonatal abstinence syndrome
Withdrawal symptoms in neonates of mothers using substances during pregnancy
What are the common substances that cause neonatal abstinence syndrome
Opiates
Methadone
Benzodiazepines
Cocaine
Amphetamine
Nicotine
Cannabis
Alcohol
SSRIs
How might a patient with neonatal abstinence syndrome present
Usually between 3 and 72 hours
CNS signs: irritability, increased tone, high pitched cry, not settling, tremors
Vasomotor and respiratory signs: yawning, sweating, unstable temperature, tachypnoea
Metabolic and gastrointestinal signs: poor feeding, regurgitation, vomiting, hypoglycaemia, loose stools
What is the management for neonatal abstinence syndrome
Monitor in hospital for at least 3 days
Urine test for substances
Neonate in quiet, dim room
Oral morphine for opiate withdrawal
Oral phenobarbitone for non-opiate withdrawal
Test for Hep B, Hep C, HIV
Safeguarding
Support mother to stop using
Check suitability for breast feeding
What are the effects of fetal alcohol syndrome on the baby
Microcephaly
Thin upper lip
Smooth, flat philtrum
Short palpebral fissure (horizontal distance from one eye to the other)
Learning disability
Hearing and vision problems
Cerebral palsy
What are the effects of congenital rubella syndrome on the baby
Congenital cataracts
Congenital heart disease
Learning disability
Hearing loss
Ensure mothers have had MMR vaccine
What are the effects of congenital varicella syndrome on the baby
If within first 28 weeks of gestation
Fetal growth restriction
Microcephaly
Hydrocephaly
Learning disabilities
Scars and significant skin changes
Limb hypoplasia
Cataracts
Chorioretinitis
What are the effects of congenital cytomegalovirus on the baby
Fetal growth restriction
Microcephaly
Hearing loss
Vision loss
Learning disability
Seizures
What are the effects of congenital toxoplasmosis on the baby
Intracranial calcification
Hydrocephalus
Chorioretinitis
What is sudden infant death syndrome
Cot death
Usually within first 6 months
What are the risk factors for sudden infant death syndrome
Prematurity
Low birth weight
Smoking during pregnancy
Male
How can the risk of sudden infant death syndrome be minimised
Put baby on back when not directly supervised
Keep head uncovered
Place feet at end of bed
Keep toys and blankets out of cot
Maintain comfortable temperature
Avoid smoking
Avoid co-sleeping
