Neonatology Flashcards
1
Q
Name 3 things done in routine post-delivery care
A
- Antibacterial eye ointment: prevent conjunctivitis secondary to gonococcus and chlamydia
- umbilical cord clean and dry: prevent tetanus and other infections
- Vitamin K im: prophylaxis against haemorrhagic disease of the newborn
2
Q
Name 5 adaptive pulmonary changes in neonates
A
- Preparation for breathing (start before delivery): increased cortisol, tsh, catecolamines → increased surfactant production; respiratory centre in brain matures
- First breath: triggered by many stimuli ie thermal, tactile, chemical. Need to establish FRC
- expansion of lungs = stimulus for surfactant secretion to decrease surface tension and keep alveoli open
- gas exchange occurs and blood ph level increase as co2 decreases
- this all → decreased resistance of pulmonary vasculature
3
Q
Name 8 adaptive cardiovascular changes in neonates
A
- Decreased pulmonary vascular resistance due to breathing
- No blood flow through ductus venosus (becomes ligamentum venosum later)
- increased systemic resistance
- reversal of foramen ovale shunt to left to right (becomes fossa ovalis )
- reversal of shunt through ductus anteriosus to left to right (becomes ligamentum arteriosum)
- increased oxygenation and decreased blood flow causes closure of shunts, initially functional later anatomical
> umbilical arteries: patent parts → superior vesical arteries; obliterated → medial umbilical ligaments
> obliterated umbilical vein → ligamentum teres /round ligament of liver
4
Q
Name 10 foetal risk factors for poor neonatal adaptation
A
- foetal distress
- meconium stained liquor
- premature or post term
- iugr
- multiple birth
- abnormal presentation eg breech, face
- shoulder dystoCia
- assisted delivery
- Infection
- congenital malformation
5
Q
Name 6 maternal risk factors for poor neonatal adaptation
A
- Pre-eclampsia
- chronic ht
- Diabetes
- infection
- drug use
- poly/oligo hydramnios
6
Q
Name 4 placental risk factors for poor neonatal adaptation
A
- Chorioamnionitis
- abruptio placenta
- placenta previa
- cord prolapse
7
Q
Describe how to take apgar score
A
APPEARANCE, PULSE, GRIMACE, ACTIVITY, RESPIRATION
Heart rate
O absent
1 < 100
2 >100
Respiration
O absent
1 slow irregular
2 regular, crying
Muscle tone
O limp
1 some flexion of extremities
2 active movement
Response to stimulation
O no response
1 grimace
2 cough, sneeze, cry
Colour
O blue or pale
1 body pink, extremities blue
2 pink
8
Q
Define neonate
A
First 28 days of life
9
Q
How long should mom’s viral load be undetectable before conception
A
4-6 months
10
Q
Mother viral load monitoring if newly diagnosed or known and not on treatment but art exposed? (3)
A
- After 3 months on art
- if 50 or more
-If 150, repeat at delivery
11
Q
Mother viral load monitoring if known with HIV on treatment? (3)
A
- Vl at first booking at ANC
- if > 50
- if <50 repeat at delivery
12
Q
Care of HIV exposed infant at delivery (4)
A
- All must get HIV PCR
- all must get minimum 6 weeks nevirapine prophylaxis
- give additional AZT for 6 weeks and nevirapine for 12 weeks in high risk infants (mother vl 1000 or more at delivery or in last 12 weeks of ANC / no vl result in past 12 weeks - reclassify 3-6 day postnatal visit by check vl ); unless formula fed - 6 weeks each
- Only stop nevirapine when breastfeeding mom vl <1000 or until 4 weeks after stopped breastfeeding.
- Prophylactic cotrimoxazole
AZT twice daily, NVP once
13
Q
Prevention syphilis in newborn with RPR positive mother? (3)
A
If asymptomatic baby and mom wasn’t treated / received < 3 doses benzathine benzylpenicillin / mom delivers within 4 weeks of starting treatment
- benzathine penicillin 50 000 u/kg IM stat
If symptomatic (hepatosplenomegaly, pseudoparesis, snuffles, desquamative rash esp involving palms and soles, oedema…)
- refer
- procaine penicillin 50 000 u/kg IM daily 10 days, or benzyl penicillin G 50 000 u /kg/dose 12 hourly iv 10 days
14
Q
Describe HIV testing and early infant diagnosis of HIV exposed infant after birth (9)
A
3-6 days
- follow up birth pCr results and manage
6 weeks
-Ensure that birth pcr and mom vl were checked, recorded and managed
10 weeks
- HIV pcr for all exposed infants that previously tested negative
6 months
- retest pcr in all exposed and previously negative
- HIV test for previously negative mom . if negative, no need to test baby. Do rapid test on non-exposed infant
- if positive, confirm with pcr
18 months
- Universal HIV rapid test for all infants even if not exposed
Other
- Do HIV test 6 weeks after stopping breastfeeding
- test symptomatic at any age
15
Q
HIV screening and confirmatory tests in children <18 months?
A
Screening pcr
Confirmatory pcr
16
Q
HIV screening and confirmatory tests in children 18 months to 2 years?
A
Screening rapid
Confirm PCR
17
Q
HIV screening and confirmatory tests in children more than 2 years?
A
Both rapid
18
Q
Postnatal maternal vl monitoring in newly diagnosed moms initiating treatment <28 weeks gestation? (3)
A
- Delivery (check before 6 day visit)
→ if 50 or more, recall mom and baby
→if 1000 or more, restart/extend infant prophylaxis if mom breastfeeding. Mannage accordingly. - 6 months pp
- 6 monthly during breastfeeding
19
Q
Postnatal maternal vl monitoring in moms already on art at pregnancy? (3)
A
- Delivery
→ if < 50, repeat at 6 months pp and 6 monthly while breastfeeding
→ if 50 or more, follow non suppression algorithm
20
Q
Postnatal maternal vl monitoring moms that are late presenters in ANC after 28 weeks gestation, or at delivery? (4)
A
- Delivery
- at 10-12 weeks on art
→ if < 50, repeat 6 months pp and 6 monthly while breastfeeding
→ if > 50, follow non suppression algorithm
21
Q
Maternal viral load non-suppression algorithm? (7)
A
VI 50 - 999
→ repeat in 8-10 weeks
> still 50 - 999 - repeat in 8-10 weeks
> <50 - repeat as per vl monitoring schedule
> 1000 or more - see below
- vl 1000 or more
→ start/restart/extend infant high risk prophylaxis and repeat vl in 4-6 weeks
> vl dropped by > 1 log - repeat in 8-10 weeks
> 1000 or more - consider switch to second line
22
Q
Name 6 risks of pregnant adolescents
A
- UTI, STI,
- anaemia
- pre- eclampsia, eclampsia, preterm labour
- depression, suboptimal antenatal care
- poor adherence art, elevated vl
- decreased birth weight, not breadfed, high risk death
23
Q
Prophylaxis low risk HIV exposed infant (4)
A
- Keep mom’s vl suppressed!
- Infant birth PCR,
- nevirapine once daily for 6 weeks only
- Cotrimoxazole (trimethoprim - sulfamethoxazole) from week 6 And stop when negative PCR 6 weeks or more after breast feeding And clinically HIV negative (otherwise stop at 12 weeks)
24
Q
Prophylaxis high risk HIV exposed infant (5)
A
- Birth PCR
- if no maternal vl at delivery or in last 12 weeks, commence infant on high risk prophylaxis until result can be checked at day 3-6 postnatal visit
- nevirapine once daily minimum 12 weeks, continue until mom’s vl <1000 or 4 weeks after stop breastfeeding. Exclusive formula fed baby gets nevirapine for only 6 weeks.
- Azt twice daily for 6 weeks regardless of method of feeding
- start cotrimoxazole from 6 weeks onwards
25
Management of asymptomatic infant born to a mother with Tb that was diagnosed in last 2 months of pregnancy / no response to Tb rx/ still AFB positive (5)
- Start TPT (inh 10 mg /kg/day for 6 months)
- Do not give BCG
- ensure HIV testing and prophylaxis/treat has been provided as relevant
- follow up clinical status, adherence to TPT, test and treat HIV at every visit
> if symptomatic, follow relevant algorithm,
> give BCG 2 weeks after INH completion whether HIV negative or positive
26
Management of symptomatic infant born to a mother with Tb that was diagnosed in last 2 months of pregnancy / no response to Tb rx/ still AFB positive (4)
Refer to hospital and evaluate for Tb
- No tb, other causes found → start TPT and delay BCG
- confirmed Tb → start Tb rx regimen 3 according to weight, test and treat HIV as relevant
→ give BCG 2 weeks after completion INH
27
Name the 10 steps to successful breastfeeding
- Health policies: make breastfeeding standard practice and best choice
- staff competency
- ANC
- care right after birth: encourage skin contact, help mom to put baby on breast within 1 hour after birth
- support mothers with breastfeeding: check position, attachment, sucking
- supplementing ( only if necessary)
- room / bedding in
- responsive feeding
- counsel on risks of bottles, teats, pacifiers
- discharge and refer to community sources for support
28
Minimum recommended time of breastfeeding?
12 months.
Definitely no solids before 6 months!
Best = exclusive bf 6 months, complementary feeding from 6 months with continued bf up to 2 years or more
29
Name 3 broad causes unconjugated neonatal jaundice
Increased production
Decreased hepatic uptake and conjugation
Increased entero hepatic circulation
30
Name 11 causes unconjugated neonatal jaundice to increased production
Benign intravascular
- physiological jaundice of the newborn: increased RBC breakdown due to decreased requirement high haemoglobin and shorter lifespan RBC
Benign extravascular
- cephalhaematoma
- Bruising
- subaponourotic bleed
- intraventricular bleed
Pathological hemolysis (direct Coombs tests)
- allo - immune: Abo (mom group o, infant a or B ), rh (negative mom that previously gave birth or sensitised, baby positive) minor antigen incompatibility
- non -immune:
→ RBC membrane defects: hereditary spherocytosis, elliptocytosis
→ haemoglobin: alpha thalassemia (beta and sickle cell disease do NOT present in neonates)
→ enzyme defects: G6PD deficiency, pyruvate kinase deficiency
31
Name 5 investigations to make diagnosis intravascular haemolysis in neonate
- Hb (decreasing/low)
- reticulocytes (high )
- LDH (high)
- haptoglobin (low)
- RBC fragments (smear)
32
Name 6 causes unconjugated neonatal jaundice to decreased hepatic uptake and conjugation
Physiological
- decreased net hepatic uptake
- immature liver enzymes required for conjugation
Pathological
- Breast milk jaundice (unidentified factor that interfere with bilirubin conjugation ) = but benign
- hypothyroid
- Gilbert's disease
- Criggler - najjar syndromes types 1 (complete lack UGT with bili encephalopathy) and 2 (partial)
33
Name 5 causes unconjugated neonatal jaundice to increase enterohepatic circulation
Physiological
Pathological
- breastfeeding failure jaundice
- meconium ileus
- hirschprung disease
- Intestinal atresia
34
Name 8 differences pathological and physiological jaundice (onset, age, progression, type, causes, symptoms)
- Clinical onset 24 hours or less after birth vs > 36 hours
- term > 10 days, preterm > 21 days vs less
- Bili rising quickly at 17 umol/L/h vs not
- conjugated fraction > 20% of TSB or > 34 umol/l vs only unconjugated fraction increased
- hemolysis vs none
- underlying illness vs none
- hepatomegaly vs none
- pale stool/dark urine vs none
35
Surgical condition if can't pass feeding tube through either nostril?
Choanal atresia
36
Name 2 sign bochdalek hernia
- Bowel sounds audible over chest
- scaphoid (hollow) abdomen
37
Treatment chlamydial conjunctivitis?
Oral erythromycin for 14 days
38
Treatment gonococcal conjunctivitis?
Single intramuscular dose of ceftriaxone and saline eye washes
39
Gonococcal vs chlamydiaI conjunctivitis?
Start around day 2-5 of life VS after day 5 - 2 weeks
Bilateral purulent vs red conjunctiva, mucous discharge, lid swelling
40
First line management preterm with respiratory distress syndrome?
Immediadiate nasal CPAP
41
For which conditions is surfactant therapy of proven benefit?
Respiratory distress syndrome
42
In which case should phototherapy be started immediately before blood results are out?
Jaundice in first 24 hours of life-always pathological.
43
How does therapeutic hypothermia treat hie
Prevent secondary cerebral cell damage
44
Below what gestational age should maternal antenatal corticosteroids be administered
34 weeks
45
Name 3 risk factors congenital pneumonia
- Maternal UTI
- maternal chorioamnionitis
- Rom > 18 hours
46
Define preterm
<37 weeks
47
Define post term
>42 weeks
48
Define low birth weight
< 2,5 kg
49
Define very low birth weight
< 1,5 kg
50
Define extremely low birth weight
< 1000 g
51
What medication should be started in newborn with suspected PDA dependant cardiac defect
Prostaglandins to keep it open.
52
When does anterior fontanelle close
9-18 months
53
When does posterior fontanelle close
By 3 months
54
Complication unconjugated jaundice?
Encephalopathy
55
Name 10 signs/ consequences of acute bilirubin encephalopathy
- Early: hypotonia, lethargy, poor suck, high pitched cry
- intermediate: irritability, fever, convulsions, may have opisthotonus
- advanced: severe opisthotonus, apnoea, convulsions, coma and death
56
Name 5 signs/ consequences of chronic bilirubin encephalopathy
- Athetosis
- Sensorineural deafness
- dental dysplasia
- discolouration teeth
- Intellectual deficits
57
Name 3 prophylactic indications phototherapy
- ELBW infants
- extravascular blood collections
- severe bruising, cephalhaematoma, IvH etc
58
Name contraindication phototherapy
Conjugated jaundice: causes irreversible bronze baby syndrome
59
Name 6 complications phototherapy
- Impaired bonding
- Increased insensible water loss - older lights that generate heat
- watery stools
- maculopopular skin rash
- lethargy
- potential for retinal damage
60
When not use indicated line on photherapy chart?
If risk factors for unconjugated jaundice, use one line lower
61
Rather use Ga or bw to determine phototherapy line?
Ga, only if accurate.
62
If TSB level is below phototherapy threshold and infant >12 hours old, when repeat TSB? (3)
- 1-20 below line: repeat in 6 hours or start phototherapy and repeat in 12-24 hours
- 21 -50 below line: repeat in 12-24 hours
- >50 below line: repeat until TSB is falling and/or jaundice clinically resolving
63
How often check TSB in infants receiving phototherapy? (2)
Check 12 - 24 hourly
But if > 30 above the line, check 4-6 hourly
64
When stop phototherapy?
TSB > 50 below the line. Recheck in 12-24 hours.
65
Indication phototherapy
When TSB is on or above the line.
66
Name 4 indications exchange transfusion
- TSB > 85 above exchange threshold at presentation (because don't expect it to fall within 6 hours)
- TSB remains above exchange line despite 6 hours of intensive phototherapy
- any signs acute bilirubin encephalopathy
- TSB rising quickly despite intensive phototherapy at >17 umol / L / h
67
When not use indicated line on exchange transfusion graph? (4)
Use one line lower in presence
- sepsis,
- haemolysis
- acidosis
- asphyxia
68
Moa exchange transfusion?
Remove maternal antibodies and bilirubin
69
Name 9 complications exchange transfusion
- Hypocalcaemia (due to citrate in bag to prevent clotting )
- hypoglycaemic (rbc use glucose, other feeds/fluids often stopped )
- hyperkalaemia (rbc lyse due to mechanical stressors)
- Vasospasm, arrhythmia (catheter)
- bleeding ( low platelets - dilutional)
- Infections
- graft vs host disease (thus must use irradiated blood )
- hypothermia (if blood not warmed )
- volume overload
70
Define conjugated /cholestatic jaundice
Db > 20% of TSB
71
Name 2 broad causes conjugated jaundice
- Hepato-cellular dysfunction
- obstructive
Always pathological!
72
Name 10 causes conjugated jaundice in neonate due to hepato-cellular dysfunction
Infections
- Torches: toxoplasmosis, other (syphilis, hep b), rubella, CMV, HSV.
- HIV
- parvovirus B 19
- UTI: E. coli
- sepsis: GBs, staph
Metabolic/genetic
- Galactosemia
- tyrosenemia
- Niemann - pick disease type C
- alpha 1 antitrypsin deficiency
- Gauchers
- Cystic fibrosis
Endocrine
- Hypothyroidism
- hypopituitarism
Allo-immune
Gestational allo -immune liver disease GALD
Toxins
- drugs: INH
- parenteral nutrition
Miscellaneous
Idiopathic neonatal hepatitis
73
Name 8 causes neonatal conjugated jaundice due to obstruction
Extra-hepatic
- biliary atresia
- Biliary (choledochal) cysts
- choledocal stones
- tumor/mass
- neonatal sclerosing cholangitis
- inspissated bile syndrome
Intra-hepatic
- alagille syndrome
- intra-hepatic biliary atresia
74
Name 6 differences between idiopathic neonatal hepatitis and extra-hepatic biliary atresia (essentially hepatocellular vs obstructive conjugated jaundice) (biopsy, bloods, urine stool, sonar, rx, prognosis)
- 30 - 35% cholestatic jaundice, usually present in first week life vs 33%
- pathology/biopsy show giant cells (fused hepatocytes) vs idiopathic inflammatory process → fibrosis and obliteration bile ducts
- ast/alt raised vs GGT /alp
- Urine normal colour, pigmented stool vs dark urine pale stool
- Sonar: gallbladder present vs absent
- Management nutritional support and fat soluble vitamin supplement vs urgent referral kasai portoenterostomy at < 60 days
- prognosis difficult to estimate vs <20% success if operated > 3 months
75
Name 8 findings/complications conjugated jaundice
- Encephalopathy: raised ammonia and hypoglycaemia (liver failure)
- cataracts: metabolic disease, congenital infection
- failure to thrive: advanced liver disease, metabolic disease, sepsis
- bleeding: coagulopathy due to liver future
- splenomegaly: storage diseases
- portal hypertension: signs include hepatosplenomegaly, asciles, kaput medusa
- pale stool dark urine in obstructive jaundice
- firm hepatomegaly: portal hypertension, biliary atresia
76
Management conjugated jaundice (5)
- Refer to gastroenterology
- fat soluble vitamins supplement
- MCT oil (medium chain triglycericle)
- adequate calories
- promote bile excretion: ursodeoxycholic acid
77
Approach to conjugated / direct jaundice?
Do Liver enzymes
ast/alt raised: hepatocellular causes. Multiple investigations:
- infections
- GALT
- alpha - 1-at
- TFT
- serum ferritin
- sweat test / fecal elastase
Alp/ggt raised: obstructive cause
- urine dipstic: bilirubin; pale stool
- Abdominal ultrasound: presence gallbladder, extra-hepatic bile ducts, choledochal cysts or stones, bile sludge
Liver biopsy if none of these reveal cause
78
Describe the newborn resuscitation algorithm (5)
Preterm, not breathing, poor tone
- Warm, dry and stimulate (unless < 30 weeks, wrap torso in plastic bag), clear airway if necessary
Gasping, apnoeic (consider CPAP if ongoing respiratory distress) or hr < 100
- ventilate room air 30 - 40 breaths per minute, use oxygen if prem start at 30 - 40%
- Ventilate with supplemental oxygen as required
Hr < 60
- Continue ventilating with supplemental oxygen as required and consider intubation. Start chest compressions.
- 0,1 - 0,3 ml/kg iv adrenaline (1:10 ooo), repeat every 3-5 minutes
79
Define neonatal encephalopathy
Disturbed neurologic function in earliest days of life in infants born at 35 weeks gestation or more.
80
Name 7 clinical features neonatal encephalopathy
- Abnormal state of consciousness: hyper alert, irritable, lethargic, obtunded
- Decrease spontaneous movements
- poor tone/ abnormal posturing
- absent/ partial primitive reflexes
- difficulty initiating and maintaining respiration
- feeding difficulty
- Seizures
81
How identify baby with suspected hie? (3)
- Abnormal signs consistent with acute hypoxia-ischaemia
→ apgar 5 or less at 5 and 10 minutes
→ foetal umbilical artery acidemia (ph 7 or less, or base deficit 12 or more, or both)
→ muti organ dysfunction
→ neuroimaging evidence of acute brain injury
- contributing events in close temporal proximity to labour and delivery; and risk factors
- long term neurodevelopmental outcome (spastic quadriparesis or dyskinetic cerebral palsy)
82
Name 9 sentinel events associated with hie
Foetal
- exsanguination: feto-maternal haemorrhage, twin twin transfusion syndrome
- cardiac arrhythmia in utero
Maternal
- cardio respiratory arrest
- Impaired oxygen eg asthma , pulmonary embolus
- hypovolemic shock /hypotension
Uteroplacental
- large abruptio placenta
- umbilical cord prolapse
- ruptured uterus
- hyperstimulation with oxytociC drugs
83
Treatment hie? (6)
Supportive
- ABCD
- glucose
- maintain normothermic
- fluid restriction
- monitor for seizures
→ confirmed seizures: phenobarbital, phenytoin, levebiracetam, larazepam
Neuro-protective
- therapeutic hypothermia (must be started within 6 hours of birth )
84
Which scores are used for hie
- Modified Sarnat score
- Thompson score
85
Name 7 long term complications hie
From most to least common
- cognitive impairment and developmental delay or learning difficulty
- Cerebral palsy: dyskinetic, spastic quadriplegic
- blindness / vision defects
- gross motor and coordination problems
- epilepsy
- hearing loss/deafness
- behavioral problems
86
Define neonatal hypoglycaemia
Serum glucose < 2,6
87
Name 6 congenital abnormalities of diabetic embryopathy in maternal diabetes
- CNs: NTD (anencephaly, myelomeningocoele), holoprosencephaly
- Cardiac: hypertrophic intraventricular septum, ASD, vSD, TGA, coarctation
- renal: agenisis or dysplasia, hydronephrosis
- git: small left colon, bowel atresia, anorectal malformation
- skeletal: caudal regression syndrome (sacral agenesis)
- Facial: midline clefts, microsomia, microtia/anotia
88
Define and name 6 causes hyponatremia
<130 mmol/l
Too much water (weight increased/n, bp increased /stable, normal turgor)
- excess fluid administration
- cardiac failure
- renal failure
- siadh
Too little salt (weight and bp decrease , poor skin turgor)
- extra-renal salt losses
- Congenital adrenal hyperplasia
89
name 4 causes hypernatremia
Water deficit
- preterm: transepidermal fluid losses
- Term: poor feeding due to illness, poorly established breastfeeding.
- gastrointestinal losses
Excess salt intake
- formula fed infants
90
Complication rapid correction of hypernatraemia?
Cerebral oedema
91
Name 5 causes hypocalcaemia neonate
Maternal
- hyperparathyroid
- vitamin D deficient
Infant
- hie
- IDM
- Di George syndrome (also hypo mg)
May cause seizures
92
Approach to abdominal distension in neonate? (5)
Intestinal obstruction
-Functional
- mechanical
→ upper git
→ lower
Ileus (usually due to sepsis)
Pneumoperitoneum (bowel perforation)
93
Gastroschisis vs omphalocoele? (8)
- Less common us more
- right paraumbilical defect vs central,
- covering sac absent vs present
- Free intestinal loops us firm mass including bowel, liver etC
- more associated with prematurity vs less
- necrotising enterocolitis common vs uncommon
- associated anomalies include intestinal atresia, malrotation, cryptorchidism vs trisomy syndromes, cardiac defects, beckwith wiedemann syndrome, bladder extrophy
- lower mortality vs higher
94
Pathophysiology transient tachypnoea of the newborn?
Lower concentration circulating catecholamines → reduced reabsorption of alveolar fluid via sodium channels in lung epithelium
95
Management transient tachypnoea of the newborn?
Supportive
- CPAP!
- Oxygen
- nasogastric feeds
96
Name 5 complications meconium aspiration
- Airway obstruction
- Surfactant dysfunction
- chemical pneumonitis
- pneumothorax
- pphn
97
Management meconium aspiration? (4)
No CPAP!
- mechanical ventilation
- inotropes
- sildenafil
- nitric oxide
98
Name 5 complications of administering oxygen to neonates
- Retinopathy of prematurity
- necrotising enterocolitis
- intraventricular haemorrhage
- broncopulmonary dysplasia
- chronic lung disease
99
Pathophysiology persistent pulmonary hypertension of the newborn
Leads to r-l shunting of blood across patent foramen ovale between 2 atrial chambers/across PDA pulmonary artery → aorta / intrapulmonary.
100
Name 5 causes persistent pulmonary hypertension of the newborn
- Birth asphyxia
- Meconium aspiration
- Sepsis
- diaphragmatic hernia
- sometimes primary
101
Management persistent pulmonary hypertension of the newborn (5)
- oxygenation
- Optimise mechanical ventilation, circulatory support as required, consider high frequency oscillatory ventilation hfov
- consider surfactant
- pulmonary vasodilation: inhaled nitric oxide. Consider iv /oral sildenafil
- extracorporeal membrane oxygenation ECMO as rescue therapy for severe respiratory failure
102
Compare the compositions of breastmilk vs formula vs animal milk (5)
- Water: 88% vs may need extra vs need extra
- Fats: most. Long chain polyunsaturated fatty acid nb for neuro development + lipase for easy digestion vs no lipase vs no lipase or essential fatty acids
- Protein: least but suitable. Whey > casein vs casein > whey vs casein > whey. Most protein. Beta lactoglobulins (intolerance)
- carb: lactose + oligosaccharides for infection protection vs most carbs vs least
- vitamins and minerals: sufficient unless mom deficient. better bio-availability except Vit D and iron. Vs added vitamins including iron, Vit D
breast milk anti infective factors: IgA, WBC (lymphocytes, neutrophils, macrophages), whey proteins lysozyme and lactoferrin kill organisms, oligosaccharicles prevent bacteria attach to mucosa
Growth factors
103
Name 5 infant indications to substitute breastmilk
Need specialised formula:
- galactosemia
- maple syrup urine disease
- phenylketonuria
In addition to breastmilk
- hypoglycaemia eg IDM
Separation from mom
104
Name 5 maternal indications to substitute breastmilk
- Severe illness, can't bf eg psychosis
- medication: radioactive iodine, cytotoxic chemotherapy, sedatives
- substance abuse
- HIV infection with unsupervised viral load on 2nd line art
- HIV infection, hepatitis C
105
Name 4 things breast milk is deficient in
- Calcium
- phosphate
- vitamin D
- Iron
Supplement preterm.
106
Define early onset neonatal sepsis
Within 48 - 72 hours after birth
From transplecental, ascending bacteria, exposure to pathogens during passage through birth canal
High fatality
Fulminant septicaemia
107
Define late onset neonatal sepsis
> 72 hours after birth
Acquired by contact with Health care workers, family, equipment, nutrition
108
Name 5 causative organisms of early onset neonatal sepsis
- Group B strep
- E. coli
- listeria monocytogenes
- staph aureus
- gram negatives (dangerous!) eg h influenza
109
Name 6 causative organisms of late onset neonatal sepsis
- Group B strep
- gram negatives
- coagulate negative staph
- staph aureus
- Enterococcus
- fungal
110
Name 4 causative organisms of infant sepsis
Acquired through genital tract / nosocomial/breastmilk
- HIV
- hep B
- hep C
- Hpv
111
When does adaptive immunity develop in neonates
5-7 days after delivery so rely on innate immunity from mom
112
Name 8 maternal risk factors for early onset neonatal sepsis
- premature labour <37 weeks!
- prom > 18 hours!
- chorioamnionitis/ maternal fever 38 or more!
- GBs bacteruria/previous infant with invasive GBs!
- colonisation with GBs!
- Traumatic delivery
- Meconium stained liquor
- low socioeconomic status
113
Name 5 neonatal risk factors for early onset neonatal sepsis
- Premature
- male
- low apgars
- hypothermia
- foetal distress
114
Empiric treatment for early onset neonatal sepsis (2)
- Penicillin G /ampicillin (cover staph and strep )
- amikacin (cover gram negatives and e coli)
115
Name 10 common causes congenital sepsis
Mostly and usually viruses:
- Rubella: first trimester
- CMV - most common! Foetal damage only early pregnancy.
- HSV
- vzv (chicken pox): first trimester
- hep B
- parvo B19
- hep c
- HIV
- Enterovirus
- papilloma
Bacteria, parasites, other
- toxoplasma gondii: 3rd trimester
- treponema palladum
- mycobacterium tuberculosis
- plasmodium
116
Name 7 clinical manifestations of congenital CMV
- Most asymptomatic
- sensorineural hearing loss most common.
Other
- Prematurity
- rash
- jaundice
- iugr
- hepatosplenomegaly
- neuro: microcephaly, seizures, hypotonia, lethargy, chorioretinitis, intracranial calcifications, vision loss
117
How diagnose congenital CMV in mother and infant? (3)
Mother: seroconversion positive Igg, CMV -DNA PCR on amniotic fluid (serum igM unreliable)
Infant
- Igm within 3 weeks of age
- CMV viral DNA (blood, urine, amniotic fluid, saliva or CSF collected before 3 weeks age )
118
Treatment congenital CMV
Iv ganciclovir for 6 months
119
Clinical presentation congenital rubella? (8)
- 2/3 asymptomatic at birth but develop sequelae later
- Jaundice
- petechiae : blueberry muffin rash
- hepatosplenomegaly
- hearing loss !
- low birth weight
- cataracts
- Thrombocytopenia
120
Diagnosis congenital rubella? (3)
- DNA PCR NPS, urine, CSF or blood up to 1 year age
- rubella specific ig M before 3 months
- rubella ig G between 6-12 months of age
121
Clinical features congenital toxoplasmosis (5)
> 80% asymptomatic at birth
Classic tetrad
- hydrocephalus
- cerebral calcification
- epilepsy
- chorioretinitis
Other: fever, maculopopular rash, hepatosplenomegaly, microcephaly, jaundice, deaf, cataracts, neurodevelopmental delay
122
Name 7 clinical manifestations early congenital sepsis
- Present before 2 years age
- prematurity and growth restriction
- hepatosplenomegaly
- nasal chOndritis (snuffles)
- skin rash
- neurological eg hydrocephalus
- Osteochondritis
123
Name 6 clinical manifestations late congenital sepsis
- present after 2 years
- craniofacial abnormalities
- dental abnormalities
- deafness
- interstitial keratitis
- neurosyphilis
124
Testing for syphilis? (4)
Treponemal tests (highly specific but positive for life even after treatment)
- enzyme immunoassays
- fluorescent treponema antibody absorption
Non-treponemal (highly sensitive for active diseases )
- vdrl
- RPR
125
Name 10 benefits kMC
- Maintain body temperature
- reduction crying
- sleep cycling
- cardio resp stable
- Decrease response to pain (oxytocin)
- less infections
- reduce morbidity and mortality
- breadfeeding earlier, more frequent , longer, better milk production
- psychosocial better for mom and baby
- physiological stress - cortisol decrease
126
Define late preterm
34-36.6 weeks
127
Define moderate preterm
32-34 weeks
128
Define very preterm
28-32 weeks
129
Define extreme preterm
<28 weeks
130
Define large birth weight
> 4 kg
131
Name 6 components of the "golden hour" of management of the preterm infant
- Delayed cord Clamping (improve bp and haemodynamic stability, reduce intraventricular haemorrhage, reduce NEC, reduce need vasopressors and blood transfusions)
- prevent hypothermia (don't dry preterm! place in polyethylene bag and cover head with cap, )
- respiratory stabilisation: nasal cpap and positive end expiratory pressure 4-6 cm H2O, titrate oxygen
- early admin total parenteral nutrition
- Prevent hypoglycaemia: 5-10% dextrose
- early admin antibiotics if suspect sepsis
132
Name 10 common complications of premature
- respiratory distress syndrome/ lung immaturity
- PDA
- bronchopulmonary dysplasia
- infection (late > early)
- intraventricular haemorrhage
- Hypothermia
- apnoea of prematurity
- retinopathy of prematurity
- chronic lung disease of prematurity
- metabolic bone disease of prematurity
133
Diagnosis respiratory distress syndrome? (8)
Respiratory distress with onset within 4 hours of birth
- tachypnoea
- Nasal flaring
- Sternal, intercostal recessions
- expiratory grunting
- Cyanosis
CXR
- Collapsed lungs
- diffuse uniform ground glass appearance
- air bronchogramS
134
Define pathological apnoea (2)
- Prolonged absent airflow 20 sec or more and
- bradycardia or hypoxemics
135
Name 8 causes apnoea in the newborn
- Mostly prematurity with immature respiratory centre ( dX of exclusion )
- infection
- NEC
- cardiac failure
- metabolic and electrolyte disturbances: hypothermia, hypoglycaemia, hyponatraemia
- anaemia
- seizures + intraventricular haemorrhage
- inborn errors of metabolism
136
CXR features PDA? (2)
- Cardiomegaly
- plethoric (white) lungs
137
Name 4 clinical features necrotising enterocolitis
- Abdominal distension/tender
- inability to tolerate feeds: vomiting or bile stained aspirates
- bloody stool (late sign)
- intestinal perforation presenting as peritonitiC abdomen
- systemic signs
High index suspicion in premature!
138
Pathogenesis neonatal intraventricular haemorrhage? (4)
- Most common acquired brain injury in premature.
- usually within 72 hours birth
- subependymal germinal matrix is vascular, ill supported matrix. Susceptible to damage due to alterations in blood flow/coagulation disorders
- may extend into ventricle and parenchyma
139
Diagnosis neonatal intraventricular haemorrhage? (3)
- Usually asymptomatic
- Cranial ultrasound
- routine screening day 3-4 infants <32 weeks gestation
140
Clinical presentation neonatal intraventricular haemorrhage? (7)
- Usually silent asymptomatic
- unexplained increasing ventilator support
- abnormal neurologic signs
- apnoea, bradycardia
- shock
- acute drop hb concentration
- hyperglycaemic
- unexplained acidosis
141
Define and describe pathophysiology retinopathy of prematurity
Vasculopathy → abnormal proliferation of retinal blood vessels → leaking and scarring → retinal detachment and blindness
142
How screen and follow up retinopathy of prematurity (3)
- Screen babies born < 1500g and/or <32 weeks gestation
- when: 6 weeks postnatal
- follow up: until retinopathy show signs regression/ completely vascularised
143
Define chronic lung disease of prematurity (3)
- Oxygen requirement at 28 days of life
- oxygen requirement and characteristic xray Changes at 28 days
- oxygen requirement at 36 weeks weeks postmenstrual age
144
Pathophysiology metabolic bone disease of prematurity
Secondary to phosphorous deficiency from increased urinary losses and increased requirements
145
When does routing and sucking reflex develop
34 weeks gestation
146
Why should nevus flammeus be referred? (2)
Port wine stain
- Associated with ipsilateral glaucoma-refer to ophthalmologist
- may be part of Sturge Weber syndrome: triad glaucoma, seizures, port wine stain. Involves angiomas brain and meninges → risk mental retard, hemiplegia.
147
What is port wine stain?
nevus flammeus
Ophthalmic (v1) distribution of trigeminal nerve
148
Name 10 skin markers of spinal dysraphism
High risk (do MRI)
- dermal sinus
- Lipoma
- tail
Intermediate risk (do mri/us)
- Aplasia cutis congenita
- atypical simple
- deviation gluteal furrow
Low risk (do mr/us if 2 or more)
- haemangioma
- hypertrichosis
- Mongolian spot
- nexus simplex
- port wine stain
- simple dimple
149
How determine corrected age?
Only do if baby born < 40 weeks gestation
Still < 40 weeks age: gestational age at birth (weeks) + age (weeks)
Eg baby born 28 weeks gestation and now 2 weeks old = 30 weeks corrected age
Born 28 weeks gestation and now 12 weeks old = 40 weeks corrected age
More > 40 weeks age: 40 weeks + chronological age from DOB
Eg born 28 weeks gestation and now 14 weeks old = 2 weeks corrected age
Born 28 weeks gestation and now 20 weeks old = 8 weeks corrected age (48w on chart)
150
When stop correcting for age on growth charts?
2 years chronological age
151
How classify well vs high risk vs sick neonates?
Well: term (39 - 41 weeks), normal anthropometry; pregnancy, perinatal and postnatal normal; vitals and exam normal
High risk: clinically well but risk factors. pre/post term, lbw, abnormal anthropometry, low 1 minute agar; complicated pregnancy / labour/ delivery / postnatal , were sick
Sick: eg due to acute blood loss, infection, hypoxia, hypothermia, hypoglycaemic, anemia, trauma, hyperbilirubinaemia, IVH
152
Name 5 types shock
- Hypovolaemic/hypoxia (most common neonate)
- cardiogenic
- septic
- distributive
- neurogenic
153
Name 7 causes neurogenic shock in neonate
- Placenta previa /abruptio
- umbilical cord injury
- twin - twin transfusion
- maternal feral hemorrhage
- hie
- Ivh
154
Name 3 causes cardiogenic shock in neonate
Rare
- Chd
- cardiomyopathy
- arrhythmia
155
Name 2 causes septic shock in neonate
- Bac/viral/fungal
- adrenal insufficiency
156
Name 3 causes distributive shock in neonate
- Congenital diaphragmatic hernia
- abdominal distension (nec)
- Pneumothorax
157
How transport sick neonate? (8)
Two sides
- Tubes (NG):relieve symptoms, prevent vomiting and aspiration pneumonia, improve ventilation (severely distended abdo splints diaphragm), measure and replace fluid and electrolyte loss, evaluate level of obstruction
- Warmth: incubator/space blanket /aluminium foil
- Oxygen:combat anaerobic infection, support respiration. not more than 40%! (Eye complications)
- Stabilise/prevent sepsis: evaluate and correct 5 Hs - hypoxia, hypotension, hypothermia, hypoglycaemia! (Check for every neonate); hydration
- Iv fluid
- Documents: referral letter, consent (operation, blood transfusion, contrast) , contact details family.
- Escort: qualified nurse or doctor
- Specimens
ACCEPT (Assessment, control centre, Communication, Evaluation on arrival, Prepare transport team, Packaging, Transfer)
158
Name 10 danger signs neonate
General:
- fever / hypothermia
- bleeding
- cyanosis
Anthropometry
- excessive weight loss
- poor feeding/sucking!
CNS
- lethargy!
- convulsions
- coma
Abdomen
- jaundice
- vomiting every thing!
- diarrhoea
- red umbilicus
