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Paediatrics > Neonatology > Flashcards

Neonatology Flashcards

1
Q

early onset neonatal sepsis definition

A

sepsis occurring within the first 48-72 hours of life

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2
Q

prevalence EONS

A

0.9/1000 live births and 9/1000 admissions in uk…rare
mortality rate 16%

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3
Q

most likely cause of severe neonatal infection

A

group B strep
others - e.coli, coagulase neg strep, haem influenzae and listeria monocytogenes

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4
Q

EONS pathophysiology

A

ascending infection in the mother with chorioamnionitis, perinatally via direct contact in birth canal and haematogenous spread

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5
Q

clinical features - early and late in EONS

A

early - resp distress, pneumonia, sepsis
later - sepsis and/or meningitis

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6
Q

chorioamnionitis in mothers prevention

A

can give intrapartum abx

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7
Q

risk factors for infection EONS

A

Invasive group B streptococcal infection in a previous baby
Maternal group B streptococcal colonisation, bacteriuria or infection in the current pregnancy
Prelabour rupture of membranes
Preterm birth following spontaneous labour (before 37 weeks’ gestation)
Suspected or confirmed rupture of membranes for more than 18 hours in a preterm birth
Intrapartum fever higher than 38°C, or confirmed or suspected chorioamnionitis

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8
Q

red flags for EONS

A

parental abx given to woman at any point during labour or in 24 hr period before and after birth
infection in another baby in case of multiple pregnacny

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9
Q

red flags clinical features EONS

A

resp distress starting more than 4 hours after birth
seizures
need for mechanical ventilation in a term baby
signs of shock

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10
Q

EONS ddx

A

transient tachypnoea of newborn
ARDS
meconium aspiration

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11
Q

EONS investigations

A

FBC
CRP
blood cultures
LP

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12
Q

EONS management

A

IV benzylpenicillin with gentamicin for 7-10 days if blood cultures positive or 14 days if CSF also positive
consider stopping at 36 hrs if think infection not present

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13
Q

prognosis EONS

A

mortality 2-4%
higher if low birth weight or pre term

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14
Q

prevalence neonatal jaundice

A

60% of term infants and 80% of preterm infants
unconjugated - can be physiology or pathological or conjugated which is always pathological

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15
Q

physiological jaundice

A

increased red cell breakdown - in utero fetus has high conc of Hb …broken down
immature liver - not process high billirubin
resolves by day 10
can progress to pathological if baby premature or increased cell breakdown from bruising

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16
Q

pathological jaundice

A

haemolytic disease - of newborn, ABO incompatibility, G6PD deficiency, spherocytosis
bilirubin above phototherapy threshold - likely dehhydrated aor due to bruising etc
unwell neonate - infection
prolonged jaundice - >14 days in infants, >21 days in preterm

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17
Q

prolonged jaundice causes

A

Infection
Metabolic: Hypothyroid/pituitarism, galactosaemia
Breast milk jaundice: well baby, resolves between 1.5-4 months
GI: biliary atresia, choledhocal cyst

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18
Q

risk factors for pathological jaundice

A

Prematurity, low birth weight, small for dates
Previous sibling required phototherapy
Exclusively breast fed
Jaundice <24 hours
Infant of diabetic mother

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19
Q

clinical presentation jaundice

A

colour of baby
drowsy - not waking for feeds
neuro - altered muscle tone, seizures
other - signs of infection, poor UO, abdo mass, stool remains black/not chnaging colour

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20
Q

jaundice investigations billirubin

A

Transcutaneous bilirubinometer (TCB) can be used in >35/40 gestation and >24 hours old for first measurement. TCB can be used for all subsequent measurements, providing the level remains <250 µmol/L and the child has not required treatment
Serum bilirubin to be measured if <35/40 gestation, <24 hours old or TCB >250 µmol/L

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21
Q

jaundice investigations other

A

serum billirubin
blood group and DCT
FBC
UE
infection screen
glucose 6 P dehydrogenase
LFT
TFT

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22
Q

management billirubin

A

phototherapy - look at charts
ex[ressed materal milk
consider NG and IV fluids if feeding poor
exchange transfusion - with donated blood or plasma via umbilical artery or vein
IV immunoglobulin

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23
Q

complications neonatal jaundice

A

Kernicterus, billirubin-induced brain dysfunction, can result from neonatal jaundice. Bilirubin is neurotoxic and at high levels can accumulate in the CNS gray matter causing irreversible neurological damage.

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24
Q

meconium aspiration syndrome definition

A

spectrum of disorders…various degrees of resp distress due to the aspiration of meconium stained amniotic fluid
mostly during birth, can occur antenatally

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25
Q

what is meconium

A

dark green, sticky and lumpy faecal material produced during pregnancy. usually released from bowels after birth but sometimes can pass in utero leading to MSAF

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26
Q

MSAF pathophysiology

A

the after effect of in utero peristalysis
usually is the result of foetal hypoxic stress or vagal stimulation due to cord compression…also causes foetus to gasp
once aspirated - stimulates release of vasoactive and cytokine substances…active inflammatory pathway and inhibits effect of surfactant

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27
Q

factors contributing to resp distress in MASF

A

partial/total airway obstruction - as meconium thick…atelectasis. Pulmonary pressure increases, right to left shunt through patent ductus arteriosus/foramen ovale…V/Q mismatch
- foetal hypoxia - V/Q mismatch, increase pulmonary vascular pressures, mechanical obstruction
- pulmonary inflammation - due to pro-inflammatory cytokines
- infection - meconium good medium for organisms, inflammation process predisposes to
- surfactant inactivation - increases surface tension of alveoli..reduced gas exchange
- persistent pulmonary HTN - remodeling of pulmonary vascular bed in response to hypoxia

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28
Q

major cause of morbidity and mortality in MSAF

A

PPHN

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29
Q

risk factors for MSAF

A

Gestational Age > 42 weeks
Foetal distress (tachycardia / bradycardia)
Intrapartum hypoxia secondary to placental insufficiency
Thick meconium particles
Apgar Score <7
Chorioamnionitis +/- Prolonged pre-rupture
Oligohydramnios
In utero growth restriction (IUGR)
Maternal hypertension, diabetes, pre-eclampsia or eclampsia, smoking and drug abuse

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29
Q

examination MSAF

A

Tachypnoea – a respiratory rate of >60 breaths per minute
Tachycardia – a heart rate of >160 beats per minute
Cyanosis – this requires immediate management
Grunting
Nasal flaring
Recessions – intercostal, supraclavicular, tracheal tug
Hypotension – systolic blood pressure of <70 mmHg

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29
Q

MSAF investigations

A

CXR -increased lung volumes
asymmetrical patchy pulmonary opacities
pleural effusions
pneumothorax or pneumomediastinum
multifoc
infection markers
dual pulse oximetry
ECHO
CRANIAL USS consolidation

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29
Q

ddx MSAF

A

transient tachypnoea of newborn
surfactant deficiency
persistent pulmonary HTN

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30
Q

management MSAF

A

observation - 02 sats
infant warmer
bloods
IV fluids
O2 via nasal cannula (92-97%)
CPAP or intubated
abx - if infection
bolus of surfactant or lung lavage with surfactant
inhaled NO
corticosteroids

31
Q

complications MSAF

A

air leak - pnumonothorax or pneumomediastinum
PPHN
cerebral palsy
chronic lung disease

32
Q

necrotising enterocolitis epidemiology

A

1-3/1000 births
reduced 6 fold in breastfed infants

33
Q

pathophysiology NEC

A

likely due to innate immune response to microbiota or premature infant’s gut

34
Q

risk factors NEC

A

Prematurity or very low birth weight (VLBW)
Formula feeding
Intrauterine growth restriction (IUGR)
Polycythaemia
Exchange transfusion
Hypoxia

35
Q

clinical features NEC

A

feeding intolerance
vomiting - bile or blood stained
abdo distention and haematochezia
abdo tenderness
abdo oedema
erythema
palpable bowel loobs
systemic features - apnoea, lethargy, bradycardia, decreased peripheral perfusion

36
Q

investigations NEC

A

plain abdo x ray - distended bowel loops, thickened bowel wall, intramural gas, pneumoperitoneum
FBC, UE, blood gas, blood culture

37
Q

staging NEC

A

bell scoring system
1 to 3
suspected, definite, advanced
clinical features and radiological

38
Q

prophylactic management NEC

A

antenatal steroids if premature delivery anticipated
breastfeeding
probiotics

39
Q

medical management MEC

A

if stage 1 or 2
Withhold oral feeds for 10-14 days and replace with parenteral nutrition.
IV antibiotics for 10-14 days based on local protocols.
Systemic support in the form of ventilatory support, fluid resuscitation, inotropic support, correction of acid-base balance coagulopathy and/or thrombocytopenia.1

40
Q
A
41
Q
A
42
Q

indications for NEC

A

Intestinal perforation
GI obstruction secondary to stricture formation
Deterioration despite medical management1

42
Q

surgical management NEC

A

intestinal resection with stoma formation

43
Q

complications NEC

A

intestinal perforation
sepsis
death
long term - strictures, short bowel syndrome, neu

44
Q

preterm birth definition

A

before 37 completed week’s gestation
Extreme preterm: before 28 weeks
Very preterm: 28 to 32 weeks
Moderate to late preterm: 32 to 37 weeks

45
Q
A
46
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A
47
Q
A
48
Q

number 1 cause of neonatal death globally

A

prematurity

48
Q

associations for neonatal death in premature delivery

A

life threatening conditions - pre eclampsia, renal disease
due to premature rupture of membranes
emergency event - placental abruption
40% have no identifiable cause

48
Q

epidemiology pre term

A

15 million babies each year
60% in africa and south asia as well as high income countries

49
Q

risk factors for premature delivery

A

Previous preterm delivery
Multiple pregnancy
Smoking and illicit drug use in pregnancy
Being under or overweight in pregnancy
Early Pregnancy (within 6 months of previous pregnancy)
Problems involving cervix, uterus or placenta, including infection
Certain chronic conditions such as diabetes and hypertension
Physical injury/trauma

50
Q

hx preterm labour

A

estimated due date
last menstrual period
assessment of gestational age

51
Q

examination preterm infant

A

dubowitz/ballard exam for gestational age - assess neonatal maturity - external physical and neuomuscular features to avoid hypothermia
physical features to assess - skin, lanugo, eye, ear and genital formation, posture and arm recoil

52
Q

investigations preterm infant

A

blood gas
FBC
U+E
blood culture
CRP
blood group and direct coombs test/direct antiglobulin test
CXR
abdo X ray
cranial USS

53
Q

central venous/arterial access in preterm infant

A

umbilical vein, atery

54
Q
A
55
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A
56
Q
A
57
Q

initial management pre term infant

A

if planned - tertiary level neonatal unit
antenatal steroids
magnesium sulphate - neuroprotective

57
Q

resuscitation guidlines pre term

A

Less than 23 weeks then resuscitation should not be performed
Between 23 and 23+6 weeks then there may be a decision not to start resuscitation in the best interests of the baby, especially if parents have expressed this wish.
Between 24 and 24+6 weeks, resuscitation should be commenced unless the baby is thought to be severely compromised
After 25 weeks, it is appropriate to resuscitate and start intensive care.

58
Q

resp system pre term

A

resp distress syndrome, surfactant deficient, CLD
…exogenous surfactant, intubation, CPAP, oxygen

59
Q

CVS pre term

A

hypotension, PDA
inotrope infusion, fluid, ibuprofen or indomethacin, ligation of PDA

60
Q

neuro pre term infant

A

intraventricular haemorrhage, seizures, cerebral palsy…surveillance with cranial USS, head circumferences, antiepileptic drugs, referral, follow up, awareness of stimulation

61
Q

GI pre term

A

feeding intolerance, NEC,..TPN, NG, maternal and donor expressed breast milk, abx

62
Q

renal premature

A

immature function
monitor fluid and electrolyte, consider catheter

63
Q

metabolic premature

A

jaundice, hyper or hypoglycaemia, inborn errors of metabolism…phototherapy, exchange transfusion, insulin infection, glucose via central IV access

64
Q

infection premature

A

sepsis, infection…sepsis screen, IV abx

65
Q

skin premature

A

insensible losses and increased risk of infection…nursing in warm, humid intubator, ANNT

66
Q

thermoregulation premature

A

immature…nursing in warm humid incubator, cot warmer, awareness of exposure

67
Q

eyes premature

A

retinopathy of prematurity…avoid excess o2 exposure, screening, laser tx

68
Q

prognosis prematurit

A

survival rare <23 weeks
by 26 weeks, 3/4 survive
90% at 27 weeks

69
Q

neurodevelopmental prognosis premature

A

gross motor delay
fine morot
speech and language
learning and behaviour

70
Q
A
71
Q
A
72
Q

family support prematurity

A

eriods of kangaroo care/skin-to-skin should be encouraged. There are often local support groups available for parents and charities such as Bliss

73
Q

ethics prematurity

A

complex…when to withdraw intensive care

74
Q
A

Paediatrics (17 decks)

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