Neonatology Flashcards
Which cells produce surfactant?
Type 2 alveolar cells
What are the 5 parts of neonatal resus?
- Warm baby
- Calculate APGAR
- Stimulate breathing
- Inflation breaths
- Chest compressions
What is used for inflation breaths?
Term babies - Air
Preterm babies - Air + oxygen
What are the five parts of APGAR?
Appearance = Blue centrally, blue peripheries, pink
Pulse = Absent, <100, >100
Grimace = Absent, little response, good response
Activity = None, flexed arms/legs, active.
Respiration = Absent, weak, good/crying
The components of the Apgar score include pulse, respiratory effort, colour, muscle tone and reflex irritability.
What is caput succudaneum?
Present at birth
Oedema of the scalp at the presenting part - typically the vertex (eg patient sitting upside down)
No discolouration associated
Lump crosses suture lines
What is cephalohaematoma?
Develops several hours after birth
Collection of blood between the skull and the periosteum
Lump does not cross suture lines
Jaundice may be apparent due to blood breakdown
What is Erb’s palsy?
A result of injury to C5/C6
Internally rotated shoulder
Extended elbow
Pronated wrist
What is the most organism responsible for neonatal sepsis?
GBS
What are features of neonatal sepsis?
Respiratory distress - grunting, nasal flaring, tachypnoea
Apnoeas
Fever
Reduced tone
Jaundice
Seizures
Poor feeding
Vomiting
How is neonatal sepsis managed?
IV Benzylpenicillin + Gentamicin (suspected or confirmed neonatal sepsis)
What are some RFs for neonatal sepsis?
-prolonged rupture of membranes (>18 hours)
-previous GBS infection mother /previous birth with GBS
-low birth weight
-prematurity
-intrapartum temperature ≥38ºC/evidence of maternal chorioamnionitis
What are causes of persistent or severe neonatal hypoglycaemia?
Preterm birth
Maternal DM
IUGR
Hypothermia
Neonatal sepsis
Inborn errors of metabolism
Nesidioblastosis
Beckwith-Wiedemann syndrome
How can neonatal hypoglycaemia present?
Irritability
Tachypnoea
Pallor
Poor feedng
Drowsiness
Hypotonia
Seizures
How is neonatal hypoglycaemia treated?
Encourage normal feeding
If severe (less than 1) IV 10% dextrose
What is hypoxic ischaemic encephalopathy? What are the causes?
Damage to brain due to hypoxia during birth
Maternal shock
Intrapartum haemorrhage
Prolapsed cord
Nuchal cord (cord wrapped around neck of baby)
How can the risk of hypoxic ischaemic encephalopathy be reduced?
Therapeutic hypothermia after birth
When is jaundice pathological in neonates?
If it presents in first 24 hours of life
If it is prolonged (more than 14 days in term babies, more than 21 days in preterm babies)
What are causes of neonatal jaundice?
Can be split into causes which cause increased bilirubin production, and causes which cause decreased clearance of bilirubin
Increased production = haemolytic disease, ABO incompatibility, haemorrhage, cephalohaematoma, polycythaemia, G6PD
Decreased clearance = prematurity, breast milk jaundice, neonatal cholestasis, biliary atresia, hypothyroidism, Gilbert syndrome
What is classed as prolonged jaundice?
> 14 days in term neonates
> 21 days in preterm neonates
What is kernicterus? How can it present?
Brain damage due to excessive bilirubin - Bilirubin can cross the BBB
Floppy, drowsy baby
Poor feeding
What are risk factors for necrotising enterocolitis?
VLBW // very preterm
Formula fed
Respiratory distress
Sepsis
PDA
How does necrotising enterocolitis present?
Intolerance to feeds
Green bilious vomiting
Distended, tender abdomen
Absent bowel sounds
Blood in stools
What is seen on Abdominal XR in necrotising enterocolitis?
Dilated loops of bowel
Bowel wall oedema
Pneumatosis intestinalis (gas in bowel wall)
Pneumoperitoneum (free gas in peritoneal cavity)
Football sign = air outlining the falciform ligament
Rigler sign = air both inside and outside of the bowel
How is NEC managed?
NBM
IV Fluids
TPN
Surgery
What are causes of bilious vomiting in neonates?
Necrotising enterocolitis
Duodenal atresia
Meconium ileus
Neonate will double bubble sign on abdominal XR?
Duodenal atresia
Double bubble sign = dilation of both the duodenum and the stomach.
Bilious vomiting in a neonate with CF?
Meconium ileus
Neonate with persistent salivation/drooling?
Oesophageal atresia
What are features of fetal alcohol syndrome?
Microcephaly
Thin upper lip
Smooth, flat philtre
Short palpebral fissure
Learning disability
Behavioural difficulties
Hearing + vision problems
Cerebral palsy
What are features of congenital rubella syndrome?
Congenital cataracts
Congenital heart disease
Learning disability
Hearing loss
What are features of congenital varicella syndrome?
Fetal growth restriction
Microcephaly
Hydrocephalus
Learning difficulty
Limb hypoplasia
Scarring/skin changes in the dematomes
Cataracts
What is Exomphalos/Omphalocele and Gastroschisis?
Exomphalos/Omphacele = abdominal contents protrude through the umbilical ring - covered with a transparent sac
Gastoschisis = abdomianl contents protrude through defect in anterior abdominal wall - no covering sac
What are causes of jaundice presenting within the first 24 hours of life? How should it be investigated?
Investigate with a blood film analysis
Rhesus haemolytic disease (RHD)
ABO incompatibility
Glucose-6-phosphate dehydrogenase (G6PD) deficiency
hereditary spherocytosis
How does malrotation present?
Bilious vomiting
Haemodynamic instability
An infant born at 41 weeks gestation has respiratory distress shortly after birth. The amniotic fluid during labour is noted to be darkly stained. Shortly after the infant develops significant respiratory distress and desaturates rapidly. Given the most likely diagnosis, what complication has occurred?
A. Transient tachypnoea of the newborn
B. Persistent pulmonary hypertension
C.Pneumothorax
D. Respiratory tract infection
E. Tracheo-oesophageal fistula
C. Pneumothorax
The baby has meconium aspiration syndrome, which is associated with high rates of air leak, pneumothorax and pneumomediastinum. The sudden development of profound respiratory distress suggests a pneumothorax.
Not B:
This is the failure of the foetal circulation to adapt to extra-uterine conditions. Meconium aspiration causes hypoxia and pulmonary vasoconstriction, maintaining higher pulmonary pressures
What is seen on abdominal XR in meconium ileus?
Air-fluid levels
How does meconium ileus present?
Failure to pass meconium within 48hrs
Billous vomiting
Abdominal distension
What is transient tachypnoea of the newborn and how does it present?
Most common cause of respiratory distress in the newborn period
Delayed resorption of fluid in the lungs
Low oxygen sats at birth
Resolves within a couple of days
What is seen on CXR in transient tachypnoea of the newborn?
Hyperinflation of the lungs
Fluid in the horizontal fissure
Duodenal atresia vs. Malrotation
Both present with billous vomiting
Duodenal atresia = few hours after birth
Malrotation = 3-7 days after birth + signs of haemodynamical instability
How is malrotation managed?
Ladd’s procedure
How does the abdomen feel in duodenal atresia?
Soft, distended
How does meconium aspiration syndrome present?
Respiratory distress
Patchy infiltrates on CXR
What is transient tachypnoea of the newborn and how does it present?
Most common cause of respiratory distress in the newborn period
Delayed resorption of fluid in the lungs
Low oxygen sats at birth
Resolves within a couple of days
What is seen on CXR in transient tachypnoea of the newborn?
Hyperinflation of the lungs
Fluid in the horizontal fissure
Congenital infection: Sensorineural deafness + congenital cataracts + congenital heart disease (E.g. PDA)?
Rubella
Congenital infection: Cerebral calcification + Chorioretinitis + Hydrocephalus
Toxoplasmosis
Congenital infection: Growth retardation. + Purpuric skin lesions
Cytomegalovirus
What does neonatal resp distress + fluid in the horizontal fissure suggest?
Transient tachypnoea of the newborn
What’s the chest compression rate/ratio for infants?
Chest compressions rate of 100-120/min, ratio of 15:2
You are working with the paediatrics team who are called to an emergency C-section at 37 weeks’ gestation. Immediately after birth, the baby lets out a strong cry. As you towel the baby dry, the arms and legs resist extension, and the baby cries with stimulation. The hands and feet look a little blue, but the face and trunk are pink. The baby’s heart rate is 140 beats per minute.
What is the APGAR score of the baby?
A. 9
B. 3
C. 1
D. 5
E. 7
A. 9: One point is lost for blue extremities, which is very common immediately postpartum
How long after birth is APGAR calculated?
at 1, 5 and 10 minutes.
How long after birth is APGAR calculated?
at 1, 5 and 10 minutes.
what are the apgar score cutoffs and meanings?
-Apgar score of 7–10 as reassuring
-a score of 4–6 as moderately abnormal
- a score of 0–3 as low
Difference between caput succedanum and cephalohaematoma:
You are attending labour for an emergency Caesarean section for failure to progress. The operation goes on without any complications. The baby cries immediately after birth and there is 30 seconds of delayed cord clamping. On examination, baby is centrally pink with blueish hands and feet. Saturation probes are attached to the baby and show an oxygen saturation of 73% at 1 minute. What is the most appropriate next step in management?
A. Intubation
B. Urgent chest x-ray
C. Ventilation breaths
D. Observe and reassess at next interval
E. No further assessment required
D. Observe and reassess at next interval
In first 10 minutes of life, suboptimal SpO2 readings can be expected from a healthy neonate.
Transient cyanosis is very common initially after birth. It does not require any further management as it usually self-resolves.
APGAR scores, including appearance/colour, should be assessed at 1 min, then reassessed at 5 and 10 minutes.
paediatric BLS algorithm
The 2015 Resuscitation Council guidelines made the following changes to paediatric basic life support
compression:ventilation ratio:
1. lay rescuers should use a ratio of 30:2
- If there are two or more rescuers with a duty to respond then a ratio of 15:2 should be used
-age definitions: an infant is a child under 1 year, a child is between 1 year and puberty
Key points of algorithm (please see link attached for more details)
1. unresponsive?
2. shout for help
3. open airway
4. look, listen, feel for breathing
5. give 5 rescue breaths
6. check for signs of circulation
-infants use brachial or femoral pulse, children use femoral pulse
7. 15 chest compressions:2 rescue breaths (see above)
-chest compressions should be 100-120/min for both infants and children
-depth: depress the lower half of the sternum by at least one-third of the anterior–posterior dimension of the chest (which is approximately 4 cm for an infant and 5 cm for a child)
-in children: compress the lower half of the sternum
-in infants: use a two-thumb encircling technique for chest compression
difference between caput succedaneum & subaponeurotic haemorrhage or subgaleal haemorrhage:
A subaponeurotic haemorrhage or subgaleal haemorrhage is a rare condition seen in newborns caused by rupturing of the emissary veins that connect the dural sinuses and the scalp veins. This leads to blood accumulating in the aponeurosis of the scalp and periosteum (can cause widespread bleeding–> shock)
-These can occur secondary to ventouse delivery and are an important differential to caput succedaneum.
-They cross cranial sutures (like caput succedaneum) but run deep to the galeal aponeurosis and are bloody rather than serosanguinous or oedematous fluid in nature.
A baby born at 35 weeks gestations via normal vaginal delivery is found to be irritable 48 hours after birth and suffers a convulsion. There is no obvious head trauma or swellings. Which one of the following cranial injuries is most likely to have occurred?
A. Caput succedaneum
B. Cephalohaematoma
C. Subaponeurotic haemorrhage
D. Intraventricular haemorrhage
E. Extradural haemorrhage
D. Intraventricular haemorrhage
In neonatal practice the vast majority of IVH occur in the first 72 hours after birth, the aetiology is not well understood and it is suggested to occur as a result of birth trauma combined with cellular hypoxia, together the with the delicate neonatal CNS.
You are asked to speak to a family who have just received a diagnosis of pulmonary hypoplasia on fetal MRI. Which of the following conditions is the most common cause of pulmonary hypoplasia?
A. Polyhydramnios
B. Congenital diaphragmatic hernia
C. Diaphragm agenesis
D. Tetralogy of Fallot
E. Osteogenesis imperfecta
B. Congenital diaphragmatic hernia
Pulmonary hypoplasia in CDH occurs alongside the hernial development rather than as a direct result of it, as part of a sequence
Pulmonary hypoplasia is a term used for newborn infants with underdeveloped lungs
Causes include
oligohydramnios
congenital diaphragmatic hernia
how is retinopathy of prematurity screened for?
Undertaken by opthalmologists
- 30 – 31 weeks gestational age in babies born before 27 weeks
- 4 – 5 weeks of age in babies born after 27 weeks
Screening should happen at least every 2 weeks and can cease once the retinal vessels enter zone 3, usually at around 36 weeks gestation.
how is retinopathy of prematurity managed?
- First line is transpupillary laser photocoagulation to halt and reverse neovascularisation.
- Other options are cryotherapy and injections of intravitreal VEGF inhibitors (very low dose avastin)
- Surgery may be required if retinal detachment occurs
how is the retina divided (zones)
The retina is divided into three zones:
- Zone 1 includes the optic nerve and the macula
- Zone 2 is from the edge of zone 1 to the ora serrata, the pigmented border between the retina and ciliary body
- Zone 3 is outside the ora serrata
The retinal areas are described as a clock face, for example “there is disease from 3 to 5 o’clock”. The areas of disease are described from stage 1 (slightly abnormal vessel growth) to stage 5 (complete retinal detachment).
“Plus disease” describes additional findings, such as tortuous vessels and hazy vitreous humour.
what happens when retina is exposed to oxygen (pathophysiology):
Retinal blood vessel development starts at around 16 weeks (same time as foetal movements) and is complete by 37 – 40 weeks gestation. The blood vessels grow from the middle of the retina to the outer area. This vessel formation is stimulated by hypoxia, which is a normal condition in the retina during pregnancy.
When the retina is exposed to higher oxygen concentrations in a preterm baby, particularly with supplementary oxygen during medical care, the stimulant for normal blood vessel development is removed.
When the hypoxic environment recurs, the retina responds by producing excessive blood vessels (neovascularisation), as well as scar tissue. These abnormal blood vessels may regress and leave the retina without a blood supply. The scar tissue may cause retinal detachment.
family history questions:
eyes, heart, hip problems in family
questions to ask for DDH screening:
breech presentation (>34 weeks), when did they turn?
what is Pierre Robin sequence? mnemonic
A set of abnormalities affecting the head and face, consisting of a small lower jaw (micrognathia ), a tongue that is placed further back than normal (glossoptosis), and blockage (obstruction) of the airways.
what is microtia?
when the external ear is small and not formed properly
describe anatomical pathology in Erb’s palsy:
An Erbs palsy is the result of injury to the C5/C6 nerves in the brachial plexus during birth. It is associated with shoulder dystocia, traumatic or instrumental delivery and large birth weight.
Damaged to the C5/C6 nerves leads to weakness of shoulder abduction and external rotation, arm flexion and finger extension. This leads to the affected arm having a “waiters tip” appearance:
- Internally rotated shoulder
- Extended elbow
- Flexed wrist facing backwards (pronated)
- Lack of movement in the affected arm
- Function normally returns spontaneously within a few months. If function does not return then they may required neurosurgical input.
2 biggest causes of bilious vomiting in neonatal unit
volvulus/malroation (admit, NBM, IV fluids), xray and upper GI contrast)
what is hypospadius? management?
Hypospadias is a birth defect in boys in which the opening of the urethra is not located at the tip of the penis
-referral to urology for followup (contraindication to circumscision)
what is this?
Slate gray nevi (Mongolian blue spots)
what is port wine stain associated with?
Sturge-Weber syndrome
sturge weber syndrome mnemonic:
STURGE. S – Seizures. T – Tram track calcifications. U – U/L port wine stain and weakness (usually opposite side) R – Retardation.v
