Neonatology Flashcards
What is hypoxic ischaemic encephalopathy ?
-> Prolonged or severe hypoxia during birth leading to ischaemic brain damage.
-> HIE can lead to permanent damage to the brain, causing cerebral palsy.
Give 4 causes of HIE
ANYTHING CAUSING ASPHYXIA
-> Maternal shock
-> Intrapartum haemorrhage
-> Prolapsed cord : causing compression of the cord during birth
-> Nuchal cord : cord is wrapped around neck of the baby
What is used to grade the severity of HIE?
-Sarnat staging
What are the features of mild HIE (3)
-Poor feeding, generally irritable and hyper-alert
-Resolves within 24 hrs
-Normal prognosis
What are the features of moderate HIE (4)
-Poor feeding, lethargic hypotonic and seizures
-Can take weeks to resolve
-Up to 40% develop cerebral palsy
What are the features of severe HIE (4)
-Reduced consciousness, apnoeas, flaccid and reduced or absent reflexes
-Up to 50% mortality
-Up to 90% develop cerebral palsy
What can be done to reduce risk of severe damage from HIE
-> Therapeutic Hypothermia
-> Carefully cooling a baby in ICU to between 33 and 34 degrees, measruing with a rectal probe
-> Continued for 72 hrs, after which the baby is warmed over 6 hrs
-> Done to reduce inflammation and neuron loss after acute hypoxic injury
What 5 things are scored in apgar scores
-HR
-Resp effort
-Muscle tone
-Reflex irritability
-Colour
0-3 = very low
4-6 = moderate low
7-10 = baby is ok
Define prematurity
-Born before 37 weeks
<28 wks - extreme preterm
28-32 wks - very preterm
32-37 wks - moderate to later preterm
What 2 thing can be done to try and delay birth in an USS showing cervical length of 25mm or less before 24 wks gestation
-Prophylactic vaginal progesterone
-Prophylactic cervical cerclage -> suture in cervix to hold shut
If preterm labour is confirmed, what can done to improve outcomes?
-Tocolysis with nifedipine (CCB) to suppresses labour
- Maternal corticosteroids before 35 wks
- IV magnesium sulphate before 34 wks to protect babys brain
- Delayed cord clamping or cord milking to increase circulating blood volume and Hb in the baby
Give issues in early life following premature birth (10)
-Resp distress syndrome
-Hypothermia
-Hypoglycaemia
-Poor feeding
-Apnoea and bradycardia
-Neonatal jaundice
-Intraventricular haemorrhage
-Retinopathy of prematurity
-Necrotising enterocolitis
-Immature immune system and infection
Give 5 long term effects of prematurity
-Chronic lung disease of prematurity
-Learning and behavioural difficulties
-Susceptibility to infections
-Hearing and visual impairment
-Cerebral palsy
Why does respiratory distress syndrome occur in premature neonates?
-<32 wks there is inadequate surfactant leading to high surface tension within alveoli
-This leads to lung collapse as it is more difficult for alveoli and lungs to expand
-There is inadequate gaseous exchange, causing hypoxia, hypercapnia and resp distress
What are the options for managing respiratory distress syndrome in premature neonates
- Intubation and ventilation if severe
- Endotracheal surfactant via endotracheal tube
- CPAP
- Oxygen to maintain sats between 91 and 95% in preterm neonates
What can be given to mothers with suspected or confirmed preterm labour to reduced incidence and severity of respiratory distress syndrome in the baby
-Antenatal steroids (I.e . dexamethasone) to increase surfactant production
Give 6 short term complications of respiratory distress syndrome
-Pneumothorax
-Infection
-Apnoea
-Intraventricular haemorrhage
-Pulmonary haemorrhage
-Necrotising enterocolitis
Give 3 long term complications of respiratory distress syndrome
-Chronic lung disease of prematurity
-Retinopathy of prematurity
-Neurological, hearing and visual impairment
What is necrotising enterocolitis ?
-Disorder affecting premature neonates where part of the bowel becomes necrotic
-Death of bowel tissue can lead to perforation -> peritonitis -> shock
Give 5 risk factors for necrotising enterocolitis
-Very low birth weight or very premature
-Formula feeds
-Respiratory distress and assisted ventilation
-Sepsis
-Patient ductus arteriosus and other congenital heart disease
How can necrotising enterocolitis present ?
-Intolerance to feeds
-Vomiting, usually green bile
-Generally unwell
-Distended, tender abdomen
-Absent bowel sounds
-Blood in stool
What is the investigation of choice for diagnosing necrotising enterocolitis ?
-Abdo X-ray
-Done front on in supine position
What will an abdo x-ray show in necrotising enterocolitis ?
-Dilated loops of bowel
-Bowel wall oedema
-Gas in the bowel wall (pneumatosis intestinalis)
- Gas in portal veins
What will be seen on bloods in necrotising enterocolitis ?
-FBC : thrombocytopenia and neutropenia
-CRP : raised
-Capillary blood gas -> metabolic acidosis
-Blood culture for sepsis
How is necrotising enterocolitis managed ?
- NBM
-Total parenteral nutrition (TPN), IV fluids and antibiotics to stabilise - Nasogastric tube to drain fluid and gas from stomach and intestines
Give 8 complications of necrotising enterocolitis
-Perforation and peritonitis
-Sepsis
-Death
-Strictures
-Abscess formation
-Recurrence
-Long term stoma
-Short bowel syndrome after surgery
What is a common cause of neonatal sepsis ?
Group B streptococcus
Give 6 RF for neonatal sepsis
- Vaginal GBS colonisation
- GBS sepsis in a previous baby
- Maternal sepsis, chorioamnionitis or fever > 38ºC
- Prematurity (less than 37 weeks)
- Early (premature) rupture of membrane
- Prolonged rupture of membranes (PROM)
Give 10 features of neonatal sepsis
- Fever
- Reduced tone and activity
- Poor feeding
- Respiratory distress or apnoea
- Vomiting
- Tachycardia or bradycardia
- Hypoxia
- Jaundice within 24 hours
- Seizures
- Hypoglycaemia
Give 6 red flags for neonatal sepsis
- Confirmed or suspected sepsis in the mother
- Signs of shock
- Seizures
- Term baby needing mechanical ventilation
- Respiratory distress starting more than 4 hours after birth
- Presumed sepsis in another baby in a multiple pregnancy
what is the management steps of presumed neonatal sepsis
- Check local policy and consult paediatrician
- If there is one risk factor or clinical feature, monitor the observations and clinical condition for at least 12 hours
- If there are two or more risk factors or clinical feature of neonatal sepsis start antibiotics
- Antibiotics should be started if there is a single red flag
- Antibiotics should be given within 1 hour of making the decision to start them
- Blood cultures should be taken before antibiotics are given
- Check a baseline FBC and CRP
- Perform a lumbar puncture if infection is strongly suspected or there are features of meningitis (e.g. seizures)
what antibiotics are recommended first line for neonatal sepsis ?
IV Benzylpenicillin and gentamycin
What is the ongoing management of neonatal sepsis
- Check CRP at 24 hrs and check blood culture results at 36 hrs :
(Abx can be stopped IF baby is clinically well, blood cultures are -ve and CRP is <10)
What are the 8 increased bilirubin production causes of jaundice in neonates
- Haemolytic disease of newborn -> rhesus incompatibility
- ABO incompatibility
- Haemorrhage
- Intraventricular haemorrhage
- Cephalo-haematoma
- Polycythaemia
- Sepsis and DIC
- G6PD deficiency
what is a common cause of jaundice in the 1st 24 hrs of life
- Neonatal sepsis
- Jaundice in first 24 hrs = pathological
what are 6 decreased bilirubin clearance causes of neonatal jaundice
- Prematurity
- Breast milk jaundice
- Neonatal cholestasis
- Gilberts
- Biliary atresia
- Endocrine disorders (hypothyroid, hypopituitary)
what is physiological jaundice
-Neonate = high conc of fragile RBCs & less developed liver function
-These RBCs break down rapidly
-There is a normal rise in bilirubin shortly after birth with mild yellowing of skin and sclera from 2-7 days of age
- Usually resolves at 10 days.
What is deemed as prolonged jaundice in a neonate ?
- > 14 days in full term babies
- > 21 days in premature babies
How is neonatal jaundice managed ?
- Plot bilirubin on treatment threshold chart
- If threshold reached = phototherapy
(converets unconjugated bilirubin -> isomers that can be excreted in bile and urine)
what is kernicterus, who is at a greater risk and what are it’s complications ?
- Brain damaged caused by excessive bilirubin levels as it can cross BBB.
- Premature babies at greater risk due to immature liver
- Cerebral palsy, LD and deafness
when is screening involved for retinopathy of prematurity ?
- Babies born before 32 wks
- Done every 2 wks and can cease when retinal vessels enter zone 3.
- Screening starts at :
- > 30 – 31 weeks gestational age in babies born before 27 weeks
- > 4 – 5 weeks of age in babies born after 27 weeks
what is the management of ROP ?
- Transpupillary laser photocoagulation to stop and reverse neovascularisation
what are the medical treatment options for moderate to severe symptoms of neonatal abstinence syndrome ?
- Oral morphine sulphate for opiate withdrawal
- Oral phenobarbitone for non-opiate withdrawal
Give 4 RF for SIDS
- Prematurity
- Low birth weight
- Smoking during pregnancy
- Male baby (only slightly increased risk)
what can be done to minimise the risk of SIDS ?
- Put baby on back when not directly supervised
- Keep their head uncovered
- Place their feet at the foot of the bed to prevent them sliding down and under the blanket
- Keep the cot clear of lots of toys and blankets
- Maintain a comfortable room temperature (16 – 20 ºC)
- Avoid smoking. Avoid handling the baby after smoking
- Avoid co-sleeping, particularly on a sofa or chair
- If co-sleeping avoid alcohol, drugs, smoking, sleeping tablets or deep sleepers
-Traumatic, prolonged or instrumental delivery (e.g.ventouse)
-Soft, puffy occipital swelling that crosses suture lines
-No treatment needed, will resolve in a few days
Caput seccedaneum : fluid collecting on the scalp OUTSIDE the periosteum and caused by pressure
-Traumatic, prolonged, instrumental delivery.
-Lump on the skull, that DOES NOT CROSS suture lines
-Discolouration of the skin in the affected area
-Cephalohaematoma : collection of blood between skull and periosteum. As it is BELOW the periosteum it does not cross suture lines
Normal vaginal delivery
Convulsion within 48 hrs
No head trauma or swellings
Intra-ventricular haemorrhage -> in premature neonates can occur spontaneously
what causes an erb’s palsy
- Injury to C5/C6 during birth
- Is associated with shoulder dystocia, traumatic or instrumental delivery and large birth weight
How does Erb’s palsy present
- Internally rotated shoulder
- Elbow extended
- Flexed wrist facing backwards (pronated)
- Lack of movement in affected arm
‘waiters tip”
what is gastroschisis and its managed
- Congenital defect in the anterior abdo wall LATERAL to the umbilical cord.
- Management : vaginal delivery, take newborn to theatre within 4 hrs
what is exomphalos (omphalocoele) and its management
- Abdominal contents protrude through abdo wall but are covered by amniotic sac
- C section to protect the sac from rupture with staged repair
How is neonatal hypoglycaemia managed if asymptomatic
- Encourage normal feeding
- Monitor blood glucose
How is neonatal hypoglycaemia managed if symptomatic / very low blood glucose
- Admit
- IV 10% dextrose
What can increase the risk of cleft lip and palate
- Maternal antiepileptic use
Give the 5 steps of neonatal resus
- Warm the baby by getting them dry.
- Calculate APGAR score.
- Stimulate breathing : head in neutral position, dry vigourously.
- Inflation breathes : 2 cycles of 5 breathes lasting 3 seconds each.If no response, 30 secs of ventilation breathes.
- Chest compressions if HR remains below 60 bpm -> 3:1 ratio with ventilation breaths.
Features of neonatal hypoglycaemia
- ‘jitteriness’, irritable, tachypnoea, pallor
- Neuroglycopenic : poor feeding/sucking, weak cry, drowsy, hypotonia, seizures
- Other : apnoea, hypothermia
