Neonatology Flashcards
What classes as a neonate
‘First 28 days of life’
Realistically, includes premature babies including up to 28 days from term
Outline chronic lung disease of prematurity
Occurs in premature babies, typically those born < 28 weeks gestation
- Suffer from respiratory distress syndrome and often require O2 therapy or intubation/ventilation
State management steps for chronic lung disease of prematurity
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
State the role of surfactant and the cells that produce it
- 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)
Outline the pressure changes which occur during the first breath
- 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
For the blood spot screening, state:
- Purpose of test
- When it is taken
- How long for results to come back
- Screening test for 9 congenital conditions
- Taken on day 5 (day 8 at latest)
- Results take 6-8 weeks to come back
State the 9 congenital conditions for which the blood spot screen tests for
- Cystic fibrosis
- Sickle cell disease
- Congenital hypothyroidism
- Phenylketonuria
- MCADD
- MSUD
- IVA
- GA1
- Homocystin
State some common organisms in neonatal sepsis
- Group B strep
- E coli
- Listeria
- Klebsiella
- Staph aureus
State some risk factors for neonatal sepsis
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)
State some clinical features of neonatal sepsis and some red flag symptoms
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
Outline the management for neonatal sepsis
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
Suggest 2 first line antibiotics in neonatal sepsis
- Benzylpenicillin
- Gentamycin
Hypoxic ischaemic encephalopathy (HIE) - state the following:
- Pathophysiology
- Presentation (including any red flags)
- Management
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
Outline some causes / risk factors for Hypoxic ischaemic encephalopathy (HIE)
- Maternal shock / blood loss during labour
- Prolapsed cause (compression of cord)
- Nuchal cord (wrapped around baby’s neck)
Outline how therapeutic hypothermia can be used in Hypoxic ischaemic encephalopathy (HIE)
- 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
Neonatal jaundice - state the following:
- Pathophysiology
- Investigations
- Management
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
State some reasons why neonates are more likely to develop jaundice
- 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
State the timeline for neonatal jaundice
1. When it first appears
2. How long it takes to resolve (in most neonates)
- First appears within 2-7 days of birth
- 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
List some causes of neonatal jaundice
- Increased release of bilirubin
- Decreased removal of bilirubin
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
State the complication that can occur in neonatal jaundice, especially if premature, how it presents and the complications
Kernicterus - brain damage due to high bilirubin
Presentation:
- Less responsive / floppy baby
- Poor feeding
Complications:
- Cerebral palsy
- Learning disability
- Deafness
State how phototherapy works in neonatal jaundice
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
Respiratory distress syndrome - state the following:
- Pathophysiology
- Investigations
- Management
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
State some short term and long term complications of respiratory distress syndrome
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)
Necrotising enterocolitis - state the following:
- Pathophysiology
- Presentation (including any red flags)
- Investigations
- Management
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
List some risk factors for necrotising enterocolitis
- 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
State some signs that might be present on a abdominal x-ray of a neonate with necrotising enterocolitis
- Dilated bowel
- Bowel wall thickening and oedema
- Gas in the bowel wall (pneumatosis intestinalis)
- Gas in the portal vein
Pneumoperitoneum if perforation has occurred
State some complications of necrotising enterocolitis (short term and long term)
Short term:
- Perforation and peritonitis
- Sepsis
- Abscess formation
- Recurrence
- Death :(
Long term:
- Bowel strictures
- Long term stoma
- Short bowel syndrome (after surgery)
Outline sudden infant death syndrome (SIDS) and the age at which it commonly happens
- Sudden unexplained death in an infant
- Also known as ‘cot death’
Most common age:
- Usually occurs in first 6 months of life
State some risk factors for sudden infant death syndrome (SIDS) and advice to minimise the risk
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
State the steps to take in neonatal rescusitation (newly born)
- 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
State some of the most common congenital abnormalities
- Club foot
- Down syndrome
- Pulmonic stenosis/atresia
- Cleft lip / palate
- Limb deformities
- Congenital heart defects
- Spina bifida
State the definition of prematurity, include ranges for the following levels of prematurity
- Extreme
- Very preterm
- Moderate-late preterm
Born prior to 37 weeks gestation
Extreme: under 28 weeks
Very preterm: 28-32
Moderate-late term: 32-37 weeks
State some risk factors for prematurity
- Previous premature baby
- Family history of prematurity
- Smoking / alcohol / drugs
- Twins
- Maternal co-morbidity
- Abnormal BMI (too high or too low)
- Social deprivation
State some things that should be done in a woman presenting with suspected preterm labour (to improve outcomes for the baby)
- Corticosteroids before 35 weeks
- IV Magnesium sulphate before 34 weeks
- Tocolysis with Nifedipine
- Delayed cord clamping after birth
State some immediate and longer term effects of prematurity
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
State what a caput succedaneum and cephalohaematoma is (birth injuries) and their management, as well as highlighting the difference between them
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
When might a facial paralysis occur during delivery and how long should it take to resolve
Typically associated with a forceps delivery
Should resolve spontaneously within a few months
If this doesn’t occur, they may require neurosurgical input
Briefly describe Erbs palsy and it’s presentation and how it’s managed
‘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
Briefly describe when clavicular fracture may occur and it’s presentation
- 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
State the 2 occasions where the newborn examination is completed and who it can be done by
- Within first 72 hours (3 days)
- Repeated 6-8 weeks after birth by GP
Can be completed by:
- Paediatrician
- GP
- Trained midwife
Apnoea of prematurity - state the following:
- Pathophysiology
- Most common age
- Management
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
State some substances that can lead to neonatal abstinence syndrome if taken during pregnancy
- Alcohol
- Nicotine
- Cannabis
- Opiates
- Cocaine
- Methadone
- Benzodiazepines
- SSRI antidepressants
- Amphetamines
State some symptoms of neonatal abstinence syndrome (withdrawal)
CNS:
- Irritability
- Increased muscle tone
- Tremors
- Seizures
Vasomotor / respiratory:
- Tachypnoea
- Sweating
- Unstable temp / fevers
- Yawning
Metabolic / GI:
- Hypoglycaemia
- Diarrhoea
- Regurgitation / vomiting
- Poor feeding
Outline when and why caffeine is given in neonates
Given to all babies under 34 weeks
Helps to increased respiratory drive and reduce the chance of apnoea
Retinopathy of prematurity - state the following:
- Pathophysiology
- Common age of neonates to be affected
- Screening
- Management
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
State some risk factors for neonatal hypothermia
- Cold delivery room
- Prematurity
- Low birth weight
- IUGR or small for dates
- Hypoglycaemic
Describe some steps that can be taken to reduce hypothermia in newborn babies
- Warm delivery room
- Immediate drying
- Warm blankets and hat
- Skin-to-skin contact
- Breastfeeding
- Postpone bathing and weighing
How may hypothermia present in a neonate / young child
- Bright red, cold skin
- Bradycardia
- Tachypnea / apnoea / hypoxia
- Fatigue / drowsiness
- Poor feeding
- Distress
- Hypoglycaemia
Eventually metabolic acidosis
State how hypothermia of the newborn can be managed
Passive heating
- polyurethane caps
- plastic bag wraps
Active heating
- skin-to-skin contact
- radiant heaters
State some causes of apnoea of prematurity
- Infection
- Anaemia
- Airway obstruction
- CNS pathology
- GORD
- Neonatal abstinence syndrome
