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Neonatology Flashcards

1
Q

What is the acid base disturbance typical of pyloric stenosis

A

Hypochloraemic metabolic alkalosis

HCL loss, increased bicarb production in the gastric cells, preferential bicarb resorption in the kidneys with Cl- resorption

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2
Q

Which organisms are neonates particularly susceptible to?

A

Group B strep
E. coli
Listeria monocytogenes

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3
Q

What are the empiric antibiotics for sepsis in a neonate?

A

Cefotaxime 50mg/kg IV plus
Benzylpenicillin 60mg/kg IV

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4
Q

Why is Ceftriaxone contraindicated in neonates?

A
  • It is highly protein bound and displaces bilirubin, leading to increased risk of kernicterus (bilirubin encephalopathy)
  • It is also associated with systemic calcinosis which can be fatal
  • The cutoff is approximately >2months old when ceftriaxone can be used
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5
Q

When should Flucloxacillin be used instead of benzylpenicillin empirically?

A

> 2 months
Flucloxacillin 50mg/kg IV QID

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6
Q

How is positive pressure ventilation (PPV) initiated in newborns?

A

40-60 breaths per minute
0.21 Fi02 for full term and 0.30 for pre-term (<35 weeks) babies
Sats monitor on right hand (pre-ductal)

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7
Q

What are the indications for PPV in newborns?

A

Not breathing or ineffective breathing
HR <100

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8
Q

When and how is CPR done in newborns?

A

If HR <60bpm despite 30secs of PPV then commence CPR

2 fingers or both thumbs (recommended)
Ratio 3:1 with PPV, FiO2 1.0
Rate 90 compressions:30 inflations/min

Reassess at 30secs, if Hr>60 then cease CPR, if <60 then move on to ALS

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9
Q

What are the 1st interventions to do in a newborn who is not breathing, not crying and/or has poor tone?

A

Warm to 36.5-37.5C
Stimulate
Open airway (neutral position)

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10
Q

What are the targeted pre-ductal 02 sats in the 1st 10mins post birth?

A

1min = 60-70
2min = 65-85
3min = 70-90
4min = 75-90
5min = 80-90
10min = 85-90

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11
Q

What are the doses of IV adrenaline in the newborn?

A

10-30mcg/kg
or
<26 weeks = 0.1mls 1:10,000
27-37 weeks = 0.25mls
>38 weeks = 0.5mls

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12
Q

which newborns are most susceptible to hypothermia?

A

Premature <32 weeks
Empiric warming with polyethylene bags or sheets

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13
Q

What are the maternal risk factors for post birth resuscitation?

A

Prolonged ruptured membranes >18hr
Noi antenatal care
Maternal drug abuse
Extremes of age <16 or >35
Indigenous mother
Chroioamnionitis
Oligo/polyhydramnios
Maternal medical problems (diabetes, hypertension etc)
Pre/eclampsia
Perinatal trauma

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14
Q

What are the foetal risk factors for post birth resuscitation?

A

Preterm <35 weeks
Multiple gestation
Post term >41 weeks
Large or small for gestational age
Rhesus isoimmunisation
Congenital abnormalities
Infection
Reduced foetal movements

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15
Q

What are the intrapartum birth risk factors for post birth resuscitation?

A

Prolonged labour >24hrs
Prolapsed cord
Abnormal lie
Non-reassuring CTG
Antepartum haemorrhage
Meconium in amniotic fluid
Assisted delivery (forceps, Ventouse, CS with a GA)
Narcotics within 4hrs of birth

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16
Q

In healthy infants how long does it take for the ductus arteriosus to close?

A

20% closed with 24hrs
82% by 48hrs
100% by 96hrs

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17
Q

What are some of the causes of ineffective breathing post birth?

A

Obstruction (ie meconium aspirate)
Congenital (choanal atresia, hypoplastic lungs, pierre-robin sequence pharyngeal malformation, laryngeal web)
Iatrogenic (pneumothorax)
Infection
Neuromuscular disorders
Maternal medications (opiates, magnesium, GA for c-sec)
Trauma (C-spine fracture)
Hypoxic brain injury
TTN
Prematurity (Neonatal respiratory distress syndrome)

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18
Q

When should the cord be clamped?

A

Well and > 34 weeks = delay cord clamping >60 secs, ideally post breathing beginning

Well and <34 weeks = 30-60 secs

Unwell = Cut the cord

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19
Q

When should antenatal MgS04 be given for neuroprotection and how much?

A

Given within 24hrs of birth and ideally up to the birth in preterm deliveries <30 weeks

4gm loading dose then 1gm per hour maintenance dose (1gm = 4mmol)

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20
Q

In the newborn what is a quick method for determing ETT size?

A

The infants gestational age divided by 10 and rounded down to the closest 0.5
Ie <28 weeks = 2.5mm ETT
34-38 weeks = 3.0 to 3.5mm

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21
Q

In the newborn what is a quick method of determing how far the ETT should be inserted for oral intubation?

A

The rule of 6
The infants weight in Kg + 6cm
Ie 1000gm = 7cm
3000gm = 9cm

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22
Q

What age and size group of neonates can a supraglottic airway be considered?

A

> 34 weeks gestation
+ > 2000gm

Usually size 1 uncuffed (ie Igel) for babies 2-5kg

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23
Q

When is Umbilical vein catheterisation the preferred route of IV access? How long can it be used for

A

In newborns <800gm or in those who are difficult access/urgent resuscitation

Can be used for the first 7 to 10 days of life

24
Q

How far should an umbilical vein catheter be inserted?

A

In a resus situation ideally 3.5cm + stump length (sits below liver), or 3 to 5cm beyond the mucocutaneous junction

As a central line it should sit in the IVC above the liver as confirmed on CXR (T8 to T9 level)

25
What are the potential complications of umbilical vein catheterisation?
Air embolism Infection Bleeding Cardiac arrhythmias False passage creation/perforation Hepatic necrosis/Portal HTN Other embolism clot formation Spasm
26
What are the indications for umbilical artery catheter insertion?
Arterial BP monitoring Repeated blood sampling Acid-Base and 02 monitoring
27
What are the complications of umbilical artery catheterization?
Bleeding Perforation Embolism Thrombosis/Vasospasm leading to ischaemia (femoral, renal, mesenteric) Infection
28
When should volume expanders be used in neonatal resus and what should be used?
0-negative uncrossmatched RBC's if blood loss suspected 0.9% Saline for other causes of shock (usually sepsis) 10-20ml/kg bolus, blood may need to be repeated
29
What are the differentials for a neonate unable to pass meconium?
Hirschprung's disease - empty rectum > surgery Meconium plug syndrome - enema and stimulation Meconium ileus - Cystic fibrosis, enema, fluids +/- surgery Anorectal malformation - Imperforate anus > Surgery Neuronal intestinal dysplasia A and B - Mucosal inflammation > surgery Small L) colon syndrome - Enema +/- colostomy Megacystis-Microcolon intestinal hyperperistalsis syndrome - TPN > surgery
30
What are differentials for a neonate with intractable vomiting?
Pyloric stenosis - 2 to 6 weeks, met alkalosis, no bile Duodenal atresia - Polyhydramnios, Down syndrome Bowl obstruction - Hirschsprungs disease, imperforate anus, Volvulus, meconium ileus Oesophageal atresia Inborn errors of metabolism Necrotising enterocolitis Infection Congenital Adrenal Hyperplasia GOR
31
What are the life threatening differentials of non-billious vomiting?
Pyloric stenosis Duodenal atresia/stenosis (if proximal to the ampulla of Vater) Annular pancreas Others include GOR, blood from mothers nipple causing stomach irritation
32
What are the life threatening differentials of billious vomiting?
Malrotation/Volvulus Distal duodenal atresia Jejunileal atresia Meconium ileus Meconium plug Hirschsprungs diease Imperforate anus
33
What is the difference between unconjugated and conjugated hyperbilirubinaemia?
Unconjugated- Binds to albumin, can cross the BBB and cause kernicterus and bilirubin encephalopathy Conjugated- after liver processing, reabsorbed by the bowel, always pathological, can't cross the BBB
34
What are the maternal risk factors for jaundice in the neonate?
Diabetes Maternal infection FHx of G6PD deficiency Isoimmunisation Only breast feeding (can last up to 12 weeks, may start as early as day 3-4)
35
What are the infant risk factors for Jaundice?
Asphyxia Bruising/haematoma/haemorrhage Prematurity Sepsis or congenital infections Sibling with jaundice Delayed cord clamping Sepsis Hypothyroidism Metabolic disorders Congenital biliary disorders Physiological jaundice
36
What are the causes of unconjugated hyperbilirubinaemia?
Physiologic, most common Breast milk jaundice, 2nd Haemolysis Infectious Metabolic (ie hypothyroid) Obstruction associated (mec ileus, pyloric stenosis) Drugs (ceftriaxone)
37
What are the causes of conjugated hyperbilirubinaemia?
TORCH infections Sepsis Biliary stenosis/atresia Drugs/Toxins Cystic Fibrosis Viruses
38
What are the basic management of a neonate with CVS collapse from suspected duct dependent lesion?
Alprostadil (PGE1 infusion) Probably airway support or intubation Don't increase PVR, most important thing is not to hyperventilate the baby Keep 02 sats in the range of 70-80% Inotropes to keep SVR > PVR
39
What are the duct dependent cyanotic heart diseases?
Ebstein's anomaly (functional hypoplastic RV) Pulmonary atresia Severe pulmonary stenosis
40
Why is an Alprostadil (PGE1) infusion in cyanotic heart disease an independent risk factor for NEC?
A wide open ductus arteriosus causes a steal phenomenon from the gut vessels leading to bowel ischaemia
41
What are the 4 main causes of cardiovascular collapse in neonates not in the peri-birth period (ie >24hrs post birth)?
Sepsis Cardiac disease Metabolic disease Asphyxia
42
Why do infants have apnoea in the context of hypoxia?
Foetal adaptation to hypoxia is to conserve energy by reducing all muscle movement including respiratory muscles This remains into early infant life and thus hypoxic babies will reduce there respiratory muscle use and become apnoeic
43
What is the end point for Alprostadil infusion?
Increase dosing until either sats are above 94% pre-ductally or femoral pulses are palpable
44
How are the metabolic causes of neonatal collapse treated initially?
Stop feeds Give glucose
45
What is the difference between kernicterus and bilirubin encephalopathy?
Bilirubin encephalopathy can be acute or chronic, caused by high levels of unconjugated bilirubin crossing the BBB Kernicterus specifically refers to the yellow staining of the basal nuclei, however it is often used synonymously with chronic bilirubin encephalopathy
46
What are the risk factors for neurotoxicity from elevated unconjugated bilirubin levels?
Rapid rise in bilirubin Pre-term brith Hypoalbuminuria Other significant co-morbidities ie sepsis, asphyxia, acidosis etc
47
When is transcutaneous bilirubin (TcB) measured and what is cut-off value for starting phototherapy?
Not recommended in babies already receiving phototherapy, <35 weeks gestational age and <24hrs old TcB >250micromol/L needs a serum bilirubin TcB is more accurate as a trend than a specific number
48
How is total serum bilirubin measured and stored?
Can be venous or capillary Needs to be taken in a heparinized tube (green), light protected and stored on ice
49
What are the main differentials of jaundice in the 1st 24hrs of life?
A medical emergency, almost always pathological DDx: Acute haemolysis the main cause - ABO/Rh incompatability - G6PD deficiency - Hereditary spherocytosis Sepsis also a differential
50
What are the main differentials for jaundice from 24hrs to 10 days of life?
Physiologic jaundice Dehydration TORCH infections Blood breakdown (haematoma, haemorrhage) Sepsis Haemolysis Metabolic disease
51
What are the differentials for jaundice after 10 days of life?
Breast milk jaundice Sepsis Hypothyroidism Hypopituitarism Hypoadrenalism Haemolysis Spherocytosis G6PD Pyloric stenosis/other intestinal obstruction
52
What are the side effects of phototherapy?
Insensible water loss and dehydration Intestinal hypermotility Photosensitivity (porphyria a contraindication) Bronze baby syndrome Parental anxiety
53
Breast milk first day post colostrum? Normal No. faily feeds in neonate? Normal wet nappies day 1 and 8? What is the acceptable weight loss in the first week of life? What are stools like in the 1st week?
- Day 2-5 - 8-12 feeds per day breast feed, 6-8 times for bottle feeds, baby content post feed - 1 weet nappy 1st day, 6-8 wet nappies day 8, red staining can be normal in 1st 1-4 days (urate crystals, not blood) - <10% weight loss normal in 1st week of life, should regain to birthweight by 2 weeks, then 150-250gm per day post - Poo is meconium day 1-2, then yellow green 3-5 then yellow 6 onwards
54
What is the APGAR score?
Colour (appearance) - blue central (0), blue peripheral (1) and pink (2) Heart rate (pulse) - Absent, <100, >100 Reflexes/irritability (Grimace) - Floppy, minimal response, active or ready response to stimulation Muscle tone (activity) - Absent, flexed, active Respirations - Absent, slow and irregular, vigorous crying Mnemonic is APGAR Scored at 1 and 5 mins, then every 5mins until 20mins for scores <7
55
What are some differentials for the flat/collapsed neonate?
THE MISFITS Trauma Heart disease Endocrine Metabolic Inborn errors metabolism Sepsis Formula issues Intestinal issues (Nec, volvulus) Toxins Seizures
56
How should a post birth scalp haematoma be assessed?
Exam - Size and location - Crossing suture lines? - Dependent oedema - Displacement of earlobes - Signs of shock - Features consistent with base of skull fracture - Evidence of NAI History - Progress of haematoma - Pregnancy history - Feeding/bowels/bladder - Irritability/sleepyness - Birth history including trauma and type of delivery - Vitamine K given? - FHx of bleeding diathesis? - Post birth trauma

Paediatrics (21 decks)

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