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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
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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
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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
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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
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5
Q

Name 6 maternal risk factors for poor neonatal adaptation

A
  • Pre-eclampsia
  • chronic ht
  • Diabetes
  • infection
  • drug use
  • poly/oligo hydramnios
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6
Q

Name 4 placental risk factors for poor neonatal adaptation

A
  • Chorioamnionitis
  • abruptio placenta
  • placenta previa
  • cord prolapse
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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

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8
Q

Define neonate

A

First 28 days of life

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9
Q

How long should mom’s viral load be undetectable before conception

A

4-6 months

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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
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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
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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
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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

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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

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15
Q

HIV screening and confirmatory tests in children <18 months?

A

Screening pcr
Confirmatory pcr

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16
Q

HIV screening and confirmatory tests in children 18 months to 2 years?

A

Screening rapid
Confirm PCR

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17
Q

HIV screening and confirmatory tests in children more than 2 years?

A

Both rapid

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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
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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
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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
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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
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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
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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)
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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
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25
Q

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)

A
  • 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
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26
Q

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)

A

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

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27
Q

Name the 10 steps to successful breastfeeding

A
  • 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
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28
Q

Minimum recommended time of breastfeeding?

A

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

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29
Q

Name 3 broad causes unconjugated neonatal jaundice

A

Increased production

Decreased hepatic uptake and conjugation

Increased entero hepatic circulation

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30
Q

Name 11 causes unconjugated neonatal jaundice to increased production

A

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

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31
Q

Name 5 investigations to make diagnosis intravascular haemolysis in neonate

A
  • Hb (decreasing/low)
  • reticulocytes (high )
  • LDH (high)
  • haptoglobin (low)
  • RBC fragments (smear)
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32
Q

Name 6 causes unconjugated neonatal jaundice to decreased hepatic uptake and conjugation

A

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)

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33
Q

Name 5 causes unconjugated neonatal jaundice to increase enterohepatic circulation

A

Physiological

Pathological
- breastfeeding failure jaundice
- meconium ileus
- hirschprung disease
- Intestinal atresia

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34
Q

Name 8 differences pathological and physiological jaundice (onset, age, progression, type, causes, symptoms)

A
  • 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
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35
Q

Surgical condition if can’t pass feeding tube through either nostril?

A

Choanal atresia

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36
Q

Name 2 sign bochdalek hernia

A
  • Bowel sounds audible over chest
  • scaphoid (hollow) abdomen
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37
Q

Treatment chlamydial conjunctivitis?

A

Oral erythromycin for 14 days

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38
Q

Treatment gonococcal conjunctivitis?

A

Single intramuscular dose of ceftriaxone and saline eye washes

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39
Q

Gonococcal vs chlamydiaI conjunctivitis?

A

Start around day 2-5 of life VS after day 5 - 2 weeks
Bilateral purulent vs red conjunctiva, mucous discharge, lid swelling

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40
Q

First line management preterm with respiratory distress syndrome?

A

Immediadiate nasal CPAP

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41
Q

For which conditions is surfactant therapy of proven benefit?

A

Respiratory distress syndrome

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42
Q

In which case should phototherapy be started immediately before blood results are out?

A

Jaundice in first 24 hours of life-always pathological.

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43
Q

How does therapeutic hypothermia treat hie

A

Prevent secondary cerebral cell damage

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44
Q

Below what gestational age should maternal antenatal corticosteroids be administered

A

34 weeks

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45
Q

Name 3 risk factors congenital pneumonia

A
  • Maternal UTI
  • maternal chorioamnionitis
  • Rom > 18 hours
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46
Q

Define preterm

A

<37 weeks

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47
Q

Define post term

A

> 42 weeks

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48
Q

Define low birth weight

A

< 2,5 kg

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49
Q

Define very low birth weight

A

< 1,5 kg

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50
Q

Define extremely low birth weight

A

< 1000 g

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51
Q

What medication should be started in newborn with suspected PDA dependant cardiac defect

A

Prostaglandins to keep it open.

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52
Q

When does anterior fontanelle close

A

9-18 months

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53
Q

When does posterior fontanelle close

A

By 3 months

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54
Q

Complication unconjugated jaundice?

A

Encephalopathy

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55
Q

Name 10 signs/ consequences of acute bilirubin encephalopathy

A
  • Early: hypotonia, lethargy, poor suck, high pitched cry
  • intermediate: irritability, fever, convulsions, may have opisthotonus
  • advanced: severe opisthotonus, apnoea, convulsions, coma and death
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56
Q

Name 5 signs/ consequences of chronic bilirubin encephalopathy

A
  • Athetosis
  • Sensorineural deafness
  • dental dysplasia
  • discolouration teeth
  • Intellectual deficits
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57
Q

Name 3 prophylactic indications phototherapy

A
  • ELBW infants
  • extravascular blood collections
  • severe bruising, cephalhaematoma, IvH etc
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58
Q

Name contraindication phototherapy

A

Conjugated jaundice: causes irreversible bronze baby syndrome

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59
Q

Name 6 complications phototherapy

A
  • Impaired bonding
  • Increased insensible water loss - older lights that generate heat
  • watery stools
  • maculopopular skin rash
  • lethargy
  • potential for retinal damage
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60
Q

When not use indicated line on photherapy chart?

A

If risk factors for unconjugated jaundice, use one line lower

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61
Q

Rather use Ga or bw to determine phototherapy line?

A

Ga, only if accurate.

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62
Q

If TSB level is below phototherapy threshold and infant >12 hours old, when repeat TSB? (3)

A
  • 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
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63
Q

How often check TSB in infants receiving phototherapy? (2)

A

Check 12 - 24 hourly
But if > 30 above the line, check 4-6 hourly

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64
Q

When stop phototherapy?

A

TSB > 50 below the line. Recheck in 12-24 hours.

65
Q

Indication phototherapy

A

When TSB is on or above the line.

66
Q

Name 4 indications exchange transfusion

A
  • 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
Q

When not use indicated line on exchange transfusion graph? (4)

A

Use one line lower in presence

  • sepsis,
  • haemolysis
  • acidosis
  • asphyxia
68
Q

Moa exchange transfusion?

A

Remove maternal antibodies and bilirubin

69
Q

Name 9 complications exchange transfusion

A
  • 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
Q

Define conjugated /cholestatic jaundice

A

Db > 20% of TSB

71
Q

Name 2 broad causes conjugated jaundice

A
  • Hepato-cellular dysfunction
  • obstructive

Always pathological!

72
Q

Name 10 causes conjugated jaundice in neonate due to hepato-cellular dysfunction

A

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
Q

Name 8 causes neonatal conjugated jaundice due to obstruction

A

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
Q

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)

A
  • 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
Q

Name 8 findings/complications conjugated jaundice

A
  • 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
Q

Management conjugated jaundice (5)

A
  • Refer to gastroenterology
  • fat soluble vitamins supplement
  • MCT oil (medium chain triglycericle)
  • adequate calories
  • promote bile excretion: ursodeoxycholic acid
77
Q

Approach to conjugated / direct jaundice?

A

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
Q

Describe the newborn resuscitation algorithm (5)

A

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
Q

Define neonatal encephalopathy

A

Disturbed neurologic function in earliest days of life in infants born at 35 weeks gestation or more.

80
Q

Name 7 clinical features neonatal encephalopathy

A
  • 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
Q

How identify baby with suspected hie? (3)

A
  • 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
Q

Name 9 sentinel events associated with hie

A

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
Q

Treatment hie? (6)

A

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
Q

Which scores are used for hie

A
  • Modified Sarnat score
  • Thompson score
85
Q

Name 7 long term complications hie

A

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
Q

Define neonatal hypoglycaemia

A

Serum glucose < 2,6

87
Q

Name 6 congenital abnormalities of diabetic embryopathy in maternal diabetes

A
  • 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
Q

Define and name 6 causes hyponatremia

A

<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
Q

name 4 causes hypernatremia

A

Water deficit
- preterm: transepidermal fluid losses
- Term: poor feeding due to illness, poorly established breastfeeding.
- gastrointestinal losses

Excess salt intake
- formula fed infants

90
Q

Complication rapid correction of hypernatraemia?

A

Cerebral oedema

91
Q

Name 5 causes hypocalcaemia neonate

A

Maternal
- hyperparathyroid
- vitamin D deficient

Infant
- hie
- IDM
- Di George syndrome (also hypo mg)

May cause seizures

92
Q

Approach to abdominal distension in neonate? (5)

A

Intestinal obstruction
-Functional
- mechanical
→ upper git
→ lower

Ileus (usually due to sepsis)

Pneumoperitoneum (bowel perforation)

93
Q

Gastroschisis vs omphalocoele? (8)

A
  • 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
Q

Pathophysiology transient tachypnoea of the newborn?

A

Lower concentration circulating catecholamines → reduced reabsorption of alveolar fluid via sodium channels in lung epithelium

95
Q

Management transient tachypnoea of the newborn?

A

Supportive
- CPAP!
- Oxygen
- nasogastric feeds

96
Q

Name 5 complications meconium aspiration

A
  • Airway obstruction
  • Surfactant dysfunction
  • chemical pneumonitis
  • pneumothorax
  • pphn
97
Q

Management meconium aspiration? (4)

A

No CPAP!

  • mechanical ventilation
  • inotropes
  • sildenafil
  • nitric oxide
98
Q

Name 5 complications of administering oxygen to neonates

A
  • Retinopathy of prematurity
  • necrotising enterocolitis
  • intraventricular haemorrhage
  • broncopulmonary dysplasia
  • chronic lung disease
99
Q

Pathophysiology persistent pulmonary hypertension of the newborn

A

Leads to r-l shunting of blood across patent foramen ovale between 2 atrial chambers/across PDA pulmonary artery → aorta / intrapulmonary.

100
Q

Name 5 causes persistent pulmonary hypertension of the newborn

A
  • Birth asphyxia
  • Meconium aspiration
  • Sepsis
  • diaphragmatic hernia
  • sometimes primary
101
Q

Management persistent pulmonary hypertension of the newborn (5)

A
  • 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
Q

Compare the compositions of breastmilk vs formula vs animal milk (5)

A
  • 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
Q

Name 5 infant indications to substitute breastmilk

A

Need specialised formula:
- galactosemia
- maple syrup urine disease
- phenylketonuria

In addition to breastmilk
- hypoglycaemia eg IDM

Separation from mom

104
Q

Name 5 maternal indications to substitute breastmilk

A
  • 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
Q

Name 4 things breast milk is deficient in

A
  • Calcium
  • phosphate
  • vitamin D
  • Iron

Supplement preterm.

106
Q

Define early onset neonatal sepsis

A

Within 48 - 72 hours after birth
From transplecental, ascending bacteria, exposure to pathogens during passage through birth canal
High fatality
Fulminant septicaemia

107
Q

Define late onset neonatal sepsis

A

> 72 hours after birth
Acquired by contact with Health care workers, family, equipment, nutrition

108
Q

Name 5 causative organisms of early onset neonatal sepsis

A
  • Group B strep
  • E. coli
  • listeria monocytogenes
  • staph aureus
  • gram negatives (dangerous!) eg h influenza
109
Q

Name 6 causative organisms of late onset neonatal sepsis

A
  • Group B strep
  • gram negatives
  • coagulate negative staph
  • staph aureus
  • Enterococcus
  • fungal
110
Q

Name 4 causative organisms of infant sepsis

A

Acquired through genital tract / nosocomial/breastmilk

  • HIV
  • hep B
  • hep C
  • Hpv
111
Q

When does adaptive immunity develop in neonates

A

5-7 days after delivery so rely on innate immunity from mom

112
Q

Name 8 maternal risk factors for early onset neonatal sepsis

A
  • 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
Q

Name 5 neonatal risk factors for early onset neonatal sepsis

A
  • Premature
  • male
  • low apgars
  • hypothermia
  • foetal distress
114
Q

Empiric treatment for early onset neonatal sepsis (2)

A
  • Penicillin G /ampicillin (cover staph and strep )
  • amikacin (cover gram negatives and e coli)
115
Q

Name 10 common causes congenital sepsis

A

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
Q

Name 7 clinical manifestations of congenital CMV

A
  • Most asymptomatic
  • sensorineural hearing loss most common.

Other

  • Prematurity
  • rash
  • jaundice
  • iugr
  • hepatosplenomegaly
  • neuro: microcephaly, seizures, hypotonia, lethargy, chorioretinitis, intracranial calcifications, vision loss
117
Q

How diagnose congenital CMV in mother and infant? (3)

A

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
Q

Treatment congenital CMV

A

Iv ganciclovir for 6 months

119
Q

Clinical presentation congenital rubella? (8)

A
  • 2/3 asymptomatic at birth but develop sequelae later
  • Jaundice
  • petechiae : blueberry muffin rash
  • hepatosplenomegaly
  • hearing loss !
  • low birth weight
  • cataracts
  • Thrombocytopenia
120
Q

Diagnosis congenital rubella? (3)

A
  • 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
Q

Clinical features congenital toxoplasmosis (5)

A

> 80% asymptomatic at birth
Classic tetrad

  • hydrocephalus
  • cerebral calcification
  • epilepsy
  • chorioretinitis

Other: fever, maculopopular rash, hepatosplenomegaly, microcephaly, jaundice, deaf, cataracts, neurodevelopmental delay

122
Q

Name 7 clinical manifestations early congenital sepsis

A
  • Present before 2 years age
  • prematurity and growth restriction
  • hepatosplenomegaly
  • nasal chOndritis (snuffles)
  • skin rash
  • neurological eg hydrocephalus
  • Osteochondritis
123
Q

Name 6 clinical manifestations late congenital sepsis

A
  • present after 2 years
  • craniofacial abnormalities
  • dental abnormalities
  • deafness
  • interstitial keratitis
  • neurosyphilis
124
Q

Testing for syphilis? (4)

A

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
Q

Name 10 benefits kMC

A
  • 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
Q

Define late preterm

A

34-36.6 weeks

127
Q

Define moderate preterm

A

32-34 weeks

128
Q

Define very preterm

A

28-32 weeks

129
Q

Define extreme preterm

A

<28 weeks

130
Q

Define large birth weight

A

> 4 kg

131
Q

Name 6 components of the “golden hour” of management of the preterm infant

A
  • 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
Q

Name 10 common complications of premature

A
  • 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
Q

Diagnosis respiratory distress syndrome? (8)

A

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
Q

Define pathological apnoea (2)

A
  • Prolonged absent airflow 20 sec or more and
  • bradycardia or hypoxemics
135
Q

Name 8 causes apnoea in the newborn

A
  • 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
Q

CXR features PDA? (2)

A
  • Cardiomegaly
  • plethoric (white) lungs
137
Q

Name 4 clinical features necrotising enterocolitis

A
  • 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
Q

Pathogenesis neonatal intraventricular haemorrhage? (4)

A
  • 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
Q

Diagnosis neonatal intraventricular haemorrhage? (3)

A
  • Usually asymptomatic
  • Cranial ultrasound
  • routine screening day 3-4 infants <32 weeks gestation
140
Q

Clinical presentation neonatal intraventricular haemorrhage? (7)

A
  • Usually silent asymptomatic
  • unexplained increasing ventilator support
  • abnormal neurologic signs
  • apnoea, bradycardia
  • shock
  • acute drop hb concentration
  • hyperglycaemic
  • unexplained acidosis
141
Q

Define and describe pathophysiology retinopathy of prematurity

A

Vasculopathy → abnormal proliferation of retinal blood vessels → leaking and scarring → retinal detachment and blindness

142
Q

How screen and follow up retinopathy of prematurity (3)

A
  • Screen babies born < 1500g and/or <32 weeks gestation
  • when: 6 weeks postnatal
  • follow up: until retinopathy show signs regression/ completely vascularised
143
Q

Define chronic lung disease of prematurity (3)

A
  • 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
Q

Pathophysiology metabolic bone disease of prematurity

A

Secondary to phosphorous deficiency from increased urinary losses and increased requirements

145
Q

When does routing and sucking reflex develop

A

34 weeks gestation

146
Q

Why should nevus flammeus be referred? (2)

A

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
Q

What is port wine stain?

A

nevus flammeus

Ophthalmic (v1) distribution of trigeminal nerve

148
Q

Name 10 skin markers of spinal dysraphism

A

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
Q

How determine corrected age?

A

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
Q

When stop correcting for age on growth charts?

A

2 years chronological age

151
Q

How classify well vs high risk vs sick neonates?

A

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
Q

Name 5 types shock

A
  • Hypovolaemic/hypoxia (most common neonate)
  • cardiogenic
  • septic
  • distributive
  • neurogenic
153
Q

Name 7 causes neurogenic shock in neonate

A
  • Placenta previa /abruptio
  • umbilical cord injury
  • twin - twin transfusion
  • maternal feral hemorrhage
  • hie
  • Ivh
154
Q

Name 3 causes cardiogenic shock in neonate

A

Rare

  • Chd
  • cardiomyopathy
  • arrhythmia
155
Q

Name 2 causes septic shock in neonate

A
  • Bac/viral/fungal
  • adrenal insufficiency
156
Q

Name 3 causes distributive shock in neonate

A
  • Congenital diaphragmatic hernia
  • abdominal distension (nec)
  • Pneumothorax
157
Q

How transport sick neonate? (8)

A

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
Q

Name 10 danger signs neonate

A

General:
- fever / hypothermia
- bleeding
- cyanosis

Anthropometry
- excessive weight loss
- poor feeding/sucking!

CNS
- lethargy!
- convulsions
- coma

Abdomen
- jaundice
- vomiting every thing!
- diarrhoea
- red umbilicus

Paediatrics (15 decks)

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