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Year 4 - 3. Paediatrics > Neonatology > Flashcards

Neonatology Flashcards

1
Q

What classes as a neonate

A

‘First 28 days of life’

Realistically, includes premature babies including up to 28 days from term

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2
Q

Outline chronic lung disease of prematurity

A

Occurs in premature babies, typically those born < 28 weeks gestation
- Suffer from respiratory distress syndrome and often require O2 therapy or intubation/ventilation

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3
Q

State management steps for chronic lung disease of prematurity

A

Prevention use CPAP rather than intubation/ventilation and not over oxygenating

  • Formal sleep study to assess O2 sats during sleep
  • Protection against RSV for certain babies with Palivizumab
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4
Q

State the role of surfactant and the cells that produce it

A
  • Liquid that contains proteins and fats (with a hydrophobic and hydrophilic side)
  • Reduces surface tension in the lungs (increases lung compliance and filling)
  • Produced by type 2 pneumocytes (between 24-34 weeks)
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5
Q

Outline the pressure changes which occur during the first breath

A
  • Thorax is squeezed during labour which helps to clear fluid from the lungs
  • The first breath expands the alveoli
  • This decreases the pulmonary vascular resistance, causing a fall in right atrium pressure
  • The right atrium pressure falls below the left atrium pressure, causing the foramen ovale to close
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6
Q

For the blood spot screening, state:
- Purpose of test
- When it is taken
- How long for results to come back

A
  • Screening test for 9 congenital conditions
  • Taken on day 5 (day 8 at latest)
  • Results take 6-8 weeks to come back
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7
Q

State the 9 congenital conditions for which the blood spot screen tests for

A
  • Cystic fibrosis
  • Sickle cell disease
  • Congenital hypothyroidism
  • Phenylketonuria
  • MCADD
  • MSUD
  • IVA
  • GA1
  • Homocystin
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8
Q

State some common organisms in neonatal sepsis

A
  • Group B strep
  • E coli
  • Listeria
  • Klebsiella
  • Staph aureus
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9
Q

State some risk factors for neonatal sepsis

A

Mother:
- Maternal sepsis
- GBS colonisation in vagina of mother
- GBS and sepsis in previous baby

Baby:
- Prematurity
- Prelabour premature rupture of membranes (P-PROM) or premature rupture of membranes (PROM)

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10
Q

State some clinical features of neonatal sepsis and some red flag symptoms

A

Clinical features:
- Fever
- Tachycardia
- Hypoxia (low O2 sats)
- Jaundice within 24 hours
- Hypoglycaemia
- Vomiting
- Poor feeding
- Reduced tone / activity

Red flags:
- Sepsis in mother
- Signs of shock in baby
- Respiratory distress or needing ventilation (if term)
- Seizures

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11
Q

Outline the management for neonatal sepsis

A

Depends on level of risk factors / clinical features / red flag symptoms

  • Take blood cultures
  • FBC + CRP
  • Lumbar puncture if features of meningitis
    1 risk factors / clinical feature = monitor for 12 hours
    2 or more risk factors / clinical feature = start antibiotics
    Any red flag = start antibiotics within 1 hour

Ongoing management:
- At 24 hours: check CRP and blood cultures
- At 5 days (if still on abx): check CRP, blood cultures and lumbar puncture

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12
Q

Suggest 2 first line antibiotics in neonatal sepsis

A
  1. Benzylpenicillin
  2. Gentamycin
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13
Q

Hypoxic ischaemic encephalopathy (HIE) - state the following:
- Pathophysiology
- Presentation (including any red flags)
- Management

A

Pathophysiology:
- Occurs in neonates as a result of hypoxia during birth, leading to encephalopathy (brain malfunctioning)
- Although some hypoxia is normal during birth, if prolonged or severe then it can cause ischaemic brain damage, cerebral palsy and even death

Presentation:
- Poor feeding
- Lethargic
- Hypotonic
- Seizures
- Absent reflexes

Management:
- Supportive care in neonatal unit
- Neonatal rescusitation
- Ventilation and circulatory support
- Nutrition
- Treatment of any seizures
- May use therapeutic hypothermia
- Continuing follow up by paediatrician

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14
Q

Outline some causes / risk factors for Hypoxic ischaemic encephalopathy (HIE)

A
  • Maternal shock / blood loss during labour
  • Prolapsed cause (compression of cord)
  • Nuchal cord (wrapped around baby’s neck)
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15
Q

Outline how therapeutic hypothermia can be used in Hypoxic ischaemic encephalopathy (HIE)

A
  • Babies near term or at term can be considered for therapeutic hypothermia
  • Involves actively cooling the baby’s core temp to 33-34 degrees (using cooling blankets and cooling hat)
  • Occurs for up to 3 days

Intention is to reduce inflammation and neuronal loss after the acute hypoxic insult and reduces the risk of:
- Cerebral palsy
- Developmental delay
- Learning disability
- Blindness
- Death

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16
Q

Neonatal jaundice - state the following:
- Pathophysiology
- Investigations
- Management

A

Pathophysiology:
- Abnormally high bilirubin in the blood, leading to a yellow discolouration to the skin and eyes

Investigations:
- FBC and blood film (polycythaemia)
- Conjugated bilirubin levels (biliary atresia)
- Blood type testing (rhesus or ABO incompatibility)
- Direct Coombs test (haemolysis)
- Thyroid function
- Sepsis screen
- G6PD levels

Management:
- Close monitoring of bilirubin levels on treatment threshold charts
- If above the threshold line, treat with phototherapy

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17
Q

State some reasons why neonates are more likely to develop jaundice

A
  • Neonates have less developed liver function (until birth, bilirubin is excreted by the placenta but after birth this is no longer present)
  • Neonatal RBCs are more fragile and they have a higher concentration of RBCs in the blood
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18
Q

State the timeline for neonatal jaundice
1. When it first appears
2. How long it takes to resolve (in most neonates)

A
  1. First appears within 2-7 days of birth
  2. Generally resolves within 10 days

Jaundice within first 24 hours is pathological - can be neonatal sepsis = requires further investigation and management

If longer than 14 days (full-term) or 21 days (preterm) then consider pathological underlying cause e.g. G6PD deficiency or biliary atresia

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19
Q

List some causes of neonatal jaundice
- Increased release of bilirubin
- Decreased removal of bilirubin

A

Increased release of bilirubin
- Haemolytic disease of the newborn
- ABO incompatibility
- Haemorrhage / intraventricular haemorrhage
- Sepsis / DIC
- Polycythemia
- G6PD deficiency

Decreased removal of bilirubin
- Prematurity (immature liver)
- Neonatal cholestasis
- Gilbert syndrome
- Extrabiliary atresia
- Endocrine disorder e.g. hypothyroidism

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20
Q

State the complication that can occur in neonatal jaundice, especially if premature, how it presents and the complications

A

Kernicterus - brain damage due to high bilirubin

Presentation:
- Less responsive / floppy baby
- Poor feeding

Complications:
- Cerebral palsy
- Learning disability
- Deafness

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21
Q

State how phototherapy works in neonatal jaundice

A

Phototherapy converts unconjugated bilirubin into isomers that can be excreted in the bile, without requiring conjugation in the liver

Can double up therapy (double therapy) by using 2 light boxes

Need to measure bilirubin 12 hours after treatment, to check levels don’t rise back up after treatment

22
Q

Respiratory distress syndrome - state the following:
- Pathophysiology
- Investigations
- Management

A

Pathophysiology:
- Inadequate surfactant production, mainly affecting premature babies < 32 weeks
- Leads to high surface tension within the alveoli and atelectasis
- Overall there is inadequate gas exchange, hypoxia, hypercapnia and respiratory distress

Investigations:
- Chest x-ray would show a ground glass appearance

Management:
- Supplementary oxygen (91-95% target)
- Artificial ventilation: either CPAP or intubation / ventilation
- Endotracheal surfactant

23
Q

State some short term and long term complications of respiratory distress syndrome

A

Short term:
- Infection
- Pneumothorax
- Pulmonary haemorrhage
- Stop breathing (apnoea)
- Intraventricular haemorrhage
- Necrotising enterocolitis

Long term:
- Chronic lung disease of prematurity
- Retinopathy of prematurity
- Neurological, hearing or visual impairment (from hypoxia)

24
Q

Necrotising enterocolitis - state the following:
- Pathophysiology
- Presentation (including any red flags)
- Investigations
- Management

A

Pathophysiology:
- Condition where part of the bowel becomes necrotic
- Affects premature neonates
- Death of the bowel tissue can lead to bowel perforation, peritonitis and shock
= life threatening emergency

Presentation:
- Distended, tender abdomen
- Absent bowel sounds
- Blood in stool
- Vomiting (green bile)
- Intolerance to feeds
- Generally unwell

Investigations:
Bloods:
- FBC (thrombocytopenia or neutropenia)
- CRP (inflammation)
- Capillary blood gas (metabolic acidosis)
- Blood culture (sepsis)
Abdominal x-ray = investigation of choice

Management:
- Nil by mouth = give IV fluids, TPN and antibiotics
- NG tube to drain fluid and gas from stomach and bowel
- Immediate referral to neonatal surgical team

25
Q

List some risk factors for necrotising enterocolitis

A
  • Very premature or very low birth weight
  • Formula fed (less common in breastfed babies)
  • Sepsis
  • Ventilation to treat respiratory distress syndrome
  • Congenital heart conditions, especially patent foramen ovale
26
Q

State some signs that might be present on a abdominal x-ray of a neonate with necrotising enterocolitis

A
  • Dilated bowel
  • Bowel wall thickening and oedema
  • Gas in the bowel wall (pneumatosis intestinalis)
  • Gas in the portal vein

Pneumoperitoneum if perforation has occurred

27
Q

State some complications of necrotising enterocolitis (short term and long term)

A

Short term:
- Perforation and peritonitis
- Sepsis
- Abscess formation
- Recurrence
- Death :(

Long term:
- Bowel strictures
- Long term stoma
- Short bowel syndrome (after surgery)

28
Q

Outline sudden infant death syndrome (SIDS) and the age at which it commonly happens

A
  • Sudden unexplained death in an infant
  • Also known as ‘cot death’

Most common age:
- Usually occurs in first 6 months of life

29
Q

State some risk factors for sudden infant death syndrome (SIDS) and advice to minimise the risk

A

Risk factors:
- Prematurity
- Low birth weight
- Smoking during the pregnancy
- Male baby (very slight increased risk)

Minimise risk:
- Feet at bottom of cot (prevent slipping down)
- Keep cot clear of blankets and toys
- Avoid co-sleeping, especially on sofa or chair
- Baby on back when not directly supervised
- Uncover their head
- Avoid smoking

30
Q

State the steps to take in neonatal rescusitation (newly born)

A
  • Keep the baby warm and dry (towels and heat lamp)
  • Calculate APGAR
  • Stimulate breathing (vigorous rubbing with towel)
  • Place head in a neutral position and aspirate under direct visualisation if obstruction by menconium
  • Inflation breaths if breathing issues, 2 x 5 breaths

If no response to ventilation breaths: increase ventilation breaths to 30 seconds, then add in chest compressions (3:1 ratio of compressions to breaths

31
Q

State some of the most common congenital abnormalities

A
  • Club foot
  • Down syndrome
  • Pulmonic stenosis/atresia
  • Cleft lip / palate
  • Limb deformities
  • Congenital heart defects
  • Spina bifida
32
Q

State the definition of prematurity, include ranges for the following levels of prematurity
- Extreme
- Very preterm
- Moderate-late preterm

A

Born prior to 37 weeks gestation

Extreme: under 28 weeks
Very preterm: 28-32
Moderate-late term: 32-37 weeks

33
Q

State some risk factors for prematurity

A
  • Previous premature baby
  • Family history of prematurity
  • Smoking / alcohol / drugs
  • Twins
  • Maternal co-morbidity
  • Abnormal BMI (too high or too low)
  • Social deprivation
34
Q

State some things that should be done in a woman presenting with suspected preterm labour (to improve outcomes for the baby)

A
  • Corticosteroids before 35 weeks
  • IV Magnesium sulphate before 34 weeks
  • Tocolysis with Nifedipine
  • Delayed cord clamping after birth
35
Q

State some immediate and longer term effects of prematurity

A

Immediate effects:
- Increased risk of infection
- Respiratory distress syndrome
- Necrotising enterocilitis
- Apnoea and bradycardia
- Retinopathy of prematurity
- Neonatal jaundice
- Intraventricular haemorrhage
- Hypothermia
- Hypoglycaemia
- Poor feeding

Longer term effects:
- Chronic lung disease of prematurity and susceptibility to chest infections
- Learning / behavioural difficulties
- Movement issues e.g. cerebral palsy
- Hearing / visual impairment

36
Q

State what a caput succedaneum and cephalohaematoma is (birth injuries) and their management, as well as highlighting the difference between them

A

Caput succedaneum:
- Fluid collecting on the scalp, outside the periosteum
- Caused by pressure to a specific area on the scalp during a prolonged, traumatic or instrumental delivery
- Able to cross the suture lines
- Doesn’t require any treatment, should resolve spontaneously over a few days

Cephalohaematoma:
- Collection of blood between the skull and the periosteum
- Caused by damage to blood vessels during a prolonged, traumatic or instrumental delivery
- NOT able to cross the suture lines
- Can cause discolouration
- Usually doesn’t require treatment and generally resolves within a few months
- Risk of jaundice and anaemia

Caput succedaneum can cross the suture lines and resolves quickly, whereas a cephalohaematoma can’t, takes longer to resolve and causes discolouration, with a risk of jaundice and anaemia

37
Q

When might a facial paralysis occur during delivery and how long should it take to resolve

A

Typically associated with a forceps delivery
Should resolve spontaneously within a few months
If this doesn’t occur, they may require neurosurgical input

38
Q

Briefly describe Erbs palsy and it’s presentation and how it’s managed

A

‘Waiter’s tip’
- Damage to C5-C6 nerves during traumatic or instrumental birth
- More likely in shoulder dystocia and large birth weight

Presentation:
- Weakness of shoulder abduction, external rotation, arm flexion and finger extension

Management:
- Normally spontaneously resolves within a few months
- If this doesn’t occur, they may require neurosurgical input

39
Q

Briefly describe when clavicular fracture may occur and it’s presentation

A
  • Fracture to clavicle during traumatic birth
  • More likely in shoulder dystocia and large birth weight

Presentation:
- Pain or distress in moving the affected arm
- Asymmetry in appearance of affected arm
- Asymmetry in movements of affected arm

Management:
- Generally conservative, with immobilisation of arm (usually heals well)
- Complication includes injury to brachial plexus

40
Q

State the 2 occasions where the newborn examination is completed and who it can be done by

A
  1. Within first 72 hours (3 days)
  2. Repeated 6-8 weeks after birth by GP

Can be completed by:
- Paediatrician
- GP
- Trained midwife

41
Q

Apnoea of prematurity - state the following:
- Pathophysiology
- Most common age
- Management

A

Pathophysiology:
- Condition where breathing stops spontaneously for > 20 seconds (or shorter periods with reduced O2 sats or bradycardia)
- Due to the immaturity of autonomic nervous system

Most common age:
- Very common in premature neonates, especially those under 28 weeks
- If it’s in term infants it can indicate a pathology

Management:
- Babies are monitored with apnoea monitors which beep with each episode
- Tactile stimulation is used to restart breathing
- IV caffeine can be used to prevent recurrent episodes
- However, episodes should settle as the baby develops

42
Q

State some substances that can lead to neonatal abstinence syndrome if taken during pregnancy

A
  • Alcohol
  • Nicotine
  • Cannabis
  • Opiates
  • Cocaine
  • Methadone
  • Benzodiazepines
  • SSRI antidepressants
  • Amphetamines
43
Q

State some symptoms of neonatal abstinence syndrome (withdrawal)

A

CNS:
- Irritability
- Increased muscle tone
- Tremors
- Seizures

Vasomotor / respiratory:
- Tachypnoea
- Sweating
- Unstable temp / fevers
- Yawning

Metabolic / GI:
- Hypoglycaemia
- Diarrhoea
- Regurgitation / vomiting
- Poor feeding

44
Q

Outline when and why caffeine is given in neonates

A

Given to all babies under 34 weeks
Helps to increased respiratory drive and reduce the chance of apnoea

45
Q

Retinopathy of prematurity - state the following:
- Pathophysiology
- Common age of neonates to be affected
- Screening
- Management

A

Pathophysiology:
- Condition which affects premature / low birth weight babies (mostly < 32 weeks)
- Caused by hypoxic environment being removed by supplementary oxygen
- Abnormal development of the blood vessels in the retina, leading to scarring, retinal detachment and blindness

Most common age:
- Mostly born < 32 weeks gestation

Screening:
- All babies born < 32 weeks gestation are screened for ROP
- Occurs at least every 2 weeks, until vessels retinal vessels reach zone 3 (approx 36 weeks)

Management:
- Transpupillary (through eye) photocoagulation to reverse new blood vessels forming
- Surgery may be needed if retinal detachment occurs

46
Q

State some risk factors for neonatal hypothermia

A
  • Cold delivery room
  • Prematurity
  • Low birth weight
  • IUGR or small for dates
  • Hypoglycaemic
47
Q

Describe some steps that can be taken to reduce hypothermia in newborn babies

A
  • Warm delivery room
  • Immediate drying
  • Warm blankets and hat
  • Skin-to-skin contact
  • Breastfeeding
  • Postpone bathing and weighing
48
Q

How may hypothermia present in a neonate / young child

A
  • Bright red, cold skin
  • Bradycardia
  • Tachypnea / apnoea / hypoxia
  • Fatigue / drowsiness
  • Poor feeding
  • Distress
  • Hypoglycaemia
    Eventually metabolic acidosis
49
Q

State how hypothermia of the newborn can be managed

A

Passive heating
- polyurethane caps
- plastic bag wraps

Active heating
- skin-to-skin contact
- radiant heaters

50
Q

State some causes of apnoea of prematurity

A
  • Infection
  • Anaemia
  • Airway obstruction
  • CNS pathology
  • GORD
  • Neonatal abstinence syndrome

Year 4 - 3. Paediatrics (16 decks)

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