Neonatology Flashcards
1
Q
what are the 5 most common organisms in neonatal sepsis?
A
- GBS
- E. coli
- listeria
- klebsiella
- staph aureus
2
Q
what are the risk factors for neonatal sepsis?
A
- maternal vaginal GBS colonisation
- GBS sepsis in previous baby
- maternal sepsis
- chorioamnionitis
- maternal fever >38
- prematurity
- premature rupture of membranes
- prolonged rupture of membranes
3
Q
what are the clinical features of neonatal sepsis?
A
- fever
- reduced tone and/or activity
- poor feeding
- respiratory distress or apnoea
- vomiting
- tachy or bradycardia
- hypoxia
- jaundice within 24hrs of birth
- seizures
- hypoglycaemia
4
Q
what are the red flags for neonatal sepsis?
A
- confirmed or suspected maternal sepsis
- signs of shock
- seizures
- term baby needing mechanical ventilation
- respiratory distress starting >4hr after birth
- presumed sepsis in another baby in a multiple pregnancy
5
Q
what should be done if one risk factor or clinical feature of neonatal sepsis is identified?
A
monitor obs and clinical condition for at least 12hrs
6
Q
what should be done if more than one risk factor or clinical feature of neonatal sepsis is identified?
A
start antibiotics
7
Q
what should be done if a red flag for neonatal sepsis is identified?
A
start antibiotics
8
Q
in what time frame should antibiotics for neonatal sepsis be started?
A
within 1 hr of the decision to prescribe
9
Q
what bloods should be requested for a baby starting antibiotics for suspected neonatal sepsis?
A
- blood cultures (before abx given)
- FBC
- CRP
10
Q
in addition to blood tests, what investigation should be requested in a baby with suspected meningitis?
A
lumbar puncture
11
Q
what does NICE recommend at first line abx for neonatal sepsis?
A
benzylpenicillin and gentamicin
12
Q
what is the ongoing management of suspected neonatal sepsis?
A
- further CRP at 24hrs and again at 5 days if still on treatment
- check blood culture results at 36hrs
13
Q
when should you consider a lumbar puncture in a neonate?
A
- suspected sepsis with CRP >10
- features suspicious of meningitis e.g. seizures
14
Q
what criteria must be met to stop abx for suspected neonatal sepsis at 36hrs?
A
- baby is clinically well
- blood culture negative
- CRP <10
15
Q
what criteria must be met to stop abx for suspected neonatal sepsis at 5 days?
A
- baby is clinically well
- blood culture negative
- lumbar puncture negative
- CRP normal
16
Q
At what gestation do Type II alveolar cells become mature enough to produce surfactant?
A
24-34 weeks
17
Q
How does surfactant help with physiological ventilation?
A
- reduces surface tension
- keeps alveoli inflated and maximises surface area
- reduces force needed to expand alveoli in inspiration and promotes equal expansion of all alveoli
- increases compliance of the lungs
18
Q
How does normal labour help prepare a foetus for extrauterine life?
A
- foetal thorax is squeezed in the birth canal and fluid is cleared from the lungs
- temperature change, sounds and physical touch stimulate release of adrenalin and cortisol which promote respiratory effort
- a strong cry expands the alveoli for the first time, decreasing pulmonary vascular resistance
- consequently, pressure in the RA falls below that of the LA and there is functional closure of the foramen ovale
19
Q
What causes closure of the ductus arteriosus?
A
fall in prostaglandins due to increasing blood oxygenation
20
Q
What maintains the ductus arteriosus?
A
prostaglandins
21
Q
What does the closed ductus arteriosus become?
A
ligamentum arteriosum
22
Q
What does the closed foramen ovale become?
A
fossa ovalis
23
Q
When and why does the ductus venosus stop functioning?
A
- immediately after birth
- due to cord clamping and a lack of flow in the umbilical veins
24
Q
What does the closed ductus venosus become?
A
ligamentum venosum
25
What complications might a baby experience during and after a normal labour and delivery?
- hypoxia
- hypothermia (due to large SA:weight and being born wet)
- babies born through meconium may have this in their airway or mouth
26
What is an APGAR score used for and when is it carried out?
- an indicator of progress over the first few minutes after birth
- calculated at 1, 5 and 10 minutes as resuscitation continues
27
What are the components of an APGAR score?
- appearance (skin colour)
- pulse
- grimace (response to stimulation)
- activity (tone)
- respiration
28
What is the range of APGAR scores one can achieve?
0-10
29
How is appearance graded for an APGAR score?
```
0 = blue / pale centrally
1 = blue extremities
2 = pink
```
30
How is pulse graded for an APGAR score?
```
0 = absent
1 = below 100
2 = above 100
```
31
How is grimace graded for an APGAR score?
```
0 = no response to stimulation
1 = little response to stimulation
2 = good response to stimulation
```
32
How is activity graded for an APGAR score?
```
0 = floppy
1 = flexed arms and legs
2 = active
```
33
How is respiration graded for an APGAR score?
```
0 = absent
1 = slow / irregular
2 = strong / crying
```
34
How should baby be cared for immediately after birth (assuming no complications)?
- skin to skin
- delayed cord clamping
- dry baby
- keep warm with hat and blankets
- Vitamin K IM
- label baby
- measure weight and length
35
When should feeding be initiated after birth?
as soon as baby is alert enough
36
When should baby have it's first bath?
- whenever it is warm and stable
| - it can be delayed for days without consequence
37
What screening does baby need in the first few days of life?
- NIPE
- blood spot test
- newborn hearing test
38
What is the newborn blood spot test?
- aka heel prick test
| - screening for 9 congenital conditions using 4 samples of blood taken by pricking baby's heel
39
What conditions does the newborn blood spot test screen for?
(9 congenital conditions)
- sickle cell disease
- cystic fibrosis
- congenital hypothyroidism
- PKU
- MCADD
- MSUD
- IVA
- GA1
- homocystinuria
40
What is the NIPE? When is it carried out?
newborn and infant physical examination
- first performed within 72 hours of birth by a trained midwife or a paediatric doctor
- repeated at 6-8 weeks in GP
41
Can jaundice in a newborn be normal? Why?
Yes - there is a normal rise in bilirubin after birth which can cause a mild jaundice from 2-7 days of life where the baby is otherwise well
42
Why do neonates gets jaundiced?
- high concentration of fragile RBCs
- immature liver function
- unable to use the placenta to excrete bilirubin as they did in utero
43
What are the causes of neonatal jaundice?
```
Increased production:
- haemolytic disease of the newborn
- ABO incompatibility
- haemorrhage
- cephalo-haematoma
- polycythaemia
- sepsis +/- DIC
- G6PD deficiency
Decreased clearance:
- prematurity
- breast milk jaundice
- neonatal cholestasis
- extrahepatic biliary atresia
- endocrine disorders
- gilbert syndrome
```
44
Jaundice is the first 24 hours of life is normal. True or false?
False
- jaundice in the first 24 hours is always pathological
- often indicates neonatal sepsis
45
Why might premature babies appear more jaundiced than their term peers?
- immature liver
46
What is kernicterus? How does it present? What can it cause?
- brain damage due to high bilirubin levels
- presents as less responsive, floppy, drowsy baby with poor feeding
- can cause cerebral palsy, learning disability and deafness
47
Breast fed babies are more likely to have neonatal jaundice. True or false? Why?
True
- components of breast milk inhibit liver processing of bilirubin
- breast-fed babies are more likely to be dehydrated and have sluggish bowels so more bilirubin is absorbed in the intestine
48
When is jaundice considered "prolonged" in a newborn?
- more than 14 days in term babies
| - more then 21 days in premature babies
49
What should be done if a baby has prolonged neonatal jaundice?
investigate for an underlying cause e.g. biliary atresia, hypothyroidism, G6PD deficiency:
- FBC and blood film
- conjugated bilirubin levels
- blood typing
- direct Coombs test
- TFTs
- blood and urine cultures
- G6PD levels
50
How is neonatal jaundice managed?
- plot total bilirubin levels against age of baby (
in hours) on treatment threshold chart
- if a pt's measurements cross the threshold on the chart they will need treatment
- phototherapy is usually adequate but exchange transfusion may be required in extreme cases
51
How does phototherapy treat neonatal jaundice?
converts unconjugated bilirubin into isomers than can be excreted in urine and bile without requiring processing in the liver
52
What is SIDS?
- sudden infant death syndrome
| - an unexplained death, usually in the first 6 months of life
53
What are the risk factors for SIDS?
- prematurity
- smoking during pregnancy
- low birth weight
- male baby (only slight increased risk)
54
How can the risk of SIDS be minimised?
- put baby on their back unless supervised
- keep baby's head uncovered
- put baby at the foot end of their bed to prevent them sliding down and under the blanket
- keep baby's bed clear of blankets and toys
- maintain room temp 16-20 degrees
- share a room with baby if possible
- avoid smoking, and don't handle baby after smoking
- avoid co-sleeping, particularly in chairs / sofa
- avoid alcohol / drugs / smoking / sleeping tablets / deep sleepers if co-sleeping necessary
55
What is the CONI team?
- care of next infant team
| - provide support to a family with their next infant, following on infant death
56
What is the prevalence of SIDS in the UK?
~230 babies die from SIDS each year in the UK (0.3 per 1000 live births)
57
How do we categorise prematurity?
```
<28w = extreme preterm
28-32w = very preterm
32-37w = moderate to late preterm
```
58
What factors and circumstances are associated with premature delivery?
- social deprivation
- smoking, alcohol and drug use
- overweight and underweight mums
- maternal co-morbidities
- multiple pregnancy
- personal or FH of prematurity
59
Who would be offered prophylactic interventions aiming to delay birth?
- people with history of preterm birth
| - anyone with a cervical length of <25mm on USS
60
What options are there to delay birth in a person who has a high risk of preterm birth, but is not in labour?
- prophylactic vaginal progesterone
| - prophylactic cervical cerclage
61
What options are there to delay birth in a person who is suspected to be in preterm labour?
tocolysis with nifedipine
62
What interventions might be recommended for someone in suspected preterm labour?
- tocolysis with nifedipine to suppress labour
- maternal corticosteroids (if 35w +)
- IV magnesium sulphate (if 34w +)
- delayed cord clamping or cord milking
63
What neonatal issues are linked to prematurity?
- respiratory distress syndrome
- hypothermia
- hypoglycaemia
- poor feeding
- apnoea and bradycardia
- neonatal jaundice
- intraventricular haemorrhage
- retinopathy of prematurity
- necrotising enterocolitis
- immature immune system increases risk of infection
64
What long term issues are linked to prematurity?
- chronic lung disease of prematurity
- susceptibility to infections - particularly respiratory
- learning and behavioural difficulties
- hearing and visual impairment
- cerebral palsy
65
What is apnoea of prematurity? Who is affected?
- periods where breathing stops for more than 20 seconds (or shorter periods with desats) which are often accompanied by bradycardia
- very common in premature neonates
- occur in almost all babies born <28w
66
Why does apnoea of prematurity occur?
- immature autonomic nervous system in premature neonates
- apnoeas often signal a developing illness
- episodes will settle as baby grows
67
What is retinopathy of prematurity?
- abnormal development of blood vessels in the retina which can lead to scarring, retinal detachment and blindness
68
How is retinopathy of prematurity detected?
all babies born before 32w or under 1.5kg will be screened every two weeks from around 30-31w gestational age until normal vessel development is observed
69
What is respiratory distress syndrome?
- atelectasis (ground glass appearance on XR)
- causing inadequate gas exchange
- resulting in Type 2 Respiratory failure
70
How can respiratory distress syndrome in neonates be managed?
- antenatal steroids are preventative
- highest level support is intubation and ventilation
- endotracheal surfactant is a useful adjunct to invasive ventilation
- NIV e.g. CPAP is a halfway house
- supplementary oxygen to achieve sats 91-95% is the least invasive intervention before babies maintain their own breathing on RA
71
What is necrotising enterocolitis?
bowel necrosis in neonates which can lead to perforation and peritionitis
72
What are the risk factors for developing NEC?
- very low birth weight
- very premature
- formula feeding
- respiratory distress and assisted ventilation
- sepsis
- PDA or other congenital heart disease
73
How does NEC present?
- intolerance to feeds
- vomiting, bilious
- generally unwell
- distended, tender abdomen
- absent bowel sounds
- blood in stools
74
How is NEC diagnosed?
- supine AXR (+/- additional views)
- XR shows dilated loops of bowel, bowel wall oedema, pneumatosis intestinalis, pneumoperitoneum, gas in the portal veins
75
How are infants with NEC managed?
- NBM
- IV fluids
- TPN
- Abx
- surgery may be required
76
NEC is a medical emergency. True or false?
False - NEC is a surgical emergency
77
What are the complications of NEC?
- perforation and peritonitis
- sepsis
- strictures
- abscess
- recurrence
- long term stoma
- short bowel syndrome
- death
78
What does the WHO recommend babies are fed on?
breast milk exclusively until 6 months
79
How much milk should babies drink each day?
150ml/kg
| less in first days of life and gradually increasing to 150ml/kg over the first week
80
How often do babies feed?
- every 2-3 hours initially
- lengthening time between feeds as the baby ages
- eventually feeding on demand
81
How much weight loss is expected in the first week of babies life?
- breastfed babies can lose up to 10%
| - bottle fed can lose up to 5%
82
At what age should babies be back at their birth weight?
10 days
83
What is the most reliable sign of dehydration in babies?
weight loss
84
What is the most common reason that babies lose weigh or struggle to regain weight?
dehydration due to underfeeding
85
At what age do babies start weaning?
6 months
