Neonatology Flashcards
1
Q
What is neonatal sepsis
A
infection in the neonatal period (first 28 days) results in significant morbidity and mortality (10%)
2
Q
what are common causative organism of neonatal sepsis
A
** Group B streptococcus (GBS) **
Escherichia coli (e. coli)
Listeria
Klebsiella
Staphylococcus aureus
3
Q
what are RF for neonate sepsis
A
- 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)
4
Q
how does neonatal sepsis present
A
Respiratory distress
fever
tachycardia
Apnoea
Reduced tone and activity
jaundice
Vomiting
poor feeding
5
Q
what are red flag symptoms of neonatal sepsis
A
- 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
6
Q
what is the management for suspected neonatal sepsis if there is ONE risk factor or clinical feature
A
monitor the observations and clinical condition for at least 12 hours
7
Q
what is the management for suspected neonatal sepsis if there is TWO or more risk factor or clinical feature
A
start antibiotics
8
Q
what is the management for suspected neonatal sepsis if there is ONE red flag sign
A
start Abx
9
Q
how soon should Abx be started in neonatal sepsis
A
within 1 hr of decsion
10
Q
when should blood cultures be taken in neonatal sepsis
A
before antibiotics are given
also baseline FBC and CRP
LP if meningitis suspected
11
Q
what is 1st line Abx of neonatal sepsis and the alterantive
A
benzylpenicillin with gentamycin
alt = third generation cephalosporin (e.g. cefotaxime)
12
Q
What is the ongoing management of neonatal sepsis
A
- Check the CRP again at 24 hours
- Check the blood culture results at 36 hours
- Check the CRP again at 5 days if they are still on treatment
- Consider performing a LP if any of the CRP results are more than 10.
13
Q
When can Abx be considered being stopped in neonatal sepsis
A
- at 48 hours if clinically well, the blood cultures are negative and both CRP results are less than 10
or
- at 5/10 day if clinically well, the lumbar puncture and blood cultures are negative and the CRP has returned to normal
14
Q
what are steps of neonatal resuscitation
A
- Dry baby and maintain temperature
- Assess tone, respiratory rate, heart rate
- If gasping or not breathing give 5 inflation breaths*
- Reassess (chest movements)
- If the heart rate is not improving and <60bpm start compressions and ventilation breaths at a rate of 3:1
15
Q
what score is used to assess newborns health after birth
A
APGAR Score
appearance:
pulse
grimace = reflex irritability
activity = tone
respiration
taken at 1 min and 5 mins
16
Q
what can prolonged hypoxia lead to
A
hypoxic-ischaemic encephalopathy (HIE)
17
Q
in severe hypoxia situations what management can be considered
A
IV drugs and intubation
therapeutic hypothermia with active cooling.
18
Q
what is benefit of delayed cord clmaping
A
improved haemoglobin, iron stores and blood pressure and a reduction in intraventricular haemorrhage and necrotising enterocolitis.
19
Q
what is downside to delayed cord clamping
A
increase in neonatal jaundice, potentially requiring more phototherapy
20
Q
how long should cord clamping be delayed in uncompromised neonates
A
at least 1 min
21
Q
what is respiratory distress syndrome
A
affects premature neonates, born before the lungs start producing adequate surfactant
common <32 weeks
mortality ~40%
22
Q
what is pathophysiology of RDS
A
Inadequate surfactant leads to high surface tension within alveoli.
= lung collapse = more difficult for lungs and alveoli to expand
= inadequate gaseous exchange
23
Q
what are blood gas results of RDS
A
hypoxia, hypercapnia (high CO2)
24
Q
what are chest XRay results of RDS
A
“ground-glass” appearance
25
what are features of RDS
tachypnoea, intercostal recession, expiratory grunting and cyanosis
26
how is RDS managed before labor
mother given antenatal steroids (dexamethasone) to increase production of surfactant with suspect or confirmed preterm labour
27
how is a neonate with RDS managed
- intubation and ventilation
- Endotracheal surfactant (artificial surfactant by trach tube
- Continuous positive airway pressure (CPAP
- Supplementary oxygen 91-95% o2 stat
28
what are short term complications of RDS
- Pneumothorax
- Infection
- Apnoea
- Intraventricular haemorrhage
- Pulmonary haemorrhage
- Necrotising enterocolitis
29
what are long term complications of RDS
- Chronic lung disease of prematurity
- Retinopathy of prematurity
- Neurological, hearing and visual impairment
30
what is Hypoxic-Ischaemic Encephalopathy
occurs in neonates as a result of hypoxia during birth.
31
When should HIE be suspected in neonates
- when there are events that could lead to hypoxia during the perinatal or intrapartum period
- acidosis (pH < 7) on the umbilical artery blood gas
- poor Apgar scores
- features of mild, moderate or severe HIE (see below)
- evidence of multi organ failure.
32
what causes HIE
- Maternal shock
- Intrapartum haemorrhage
- Prolapsed cord, causing compression of the cord during birth
- Nuchal cord, where the cord is wrapped around the neck of the baby
33
what is the grading system of HIE
Sarnat Staging
34
what is mild in Sarnat Staging
Poor feeding, generally irritability and hyper-alert
Resolves within 24 hours
Normal prognosis
35
what is moderate in Sarnat Staging
- Poor feeding, lethargic, hypotonic and seizures
- Can take weeks to resolve
- Up to 40% develop cerebral palsy
36
what is severe in Sarnat Staging
- Reduced consciousness, apnoeas, flaccid and reduced or absent reflexes
- Up to 50% mortality
- Up to 90% develop cerebral palsy
37
how is HIE managed
supportive care with neonatal resuscitation
ventilation
circulatory support
nutrition
acid base balance
treatment of seizures.
Therapeutic hypothermia
38
what is Therapeutic hypothermia
actively cooling the core temperature of the baby to reduce the inflammation and neurone loss after the acute hypoxic injury
39
what is the temperate aim of Therapeutic hypothermia and for how long
between 33 and 34°C, measured using a rectal probe for 72 hours
baby is gradually warmed to a normal temperature over 6 hours
40
What is Jaundice
abnormally high levels of bilirubin in the blood
41
what do RBC contain
unconjugated bilirubin
42
where is unconjugated bilirubin conjugated
liver
43
how is conjugated bilirubin excreted
- via the biliary system into the gastrointestinal tract
- via the urine.
44
what is the physiology of neonatal jaundice
high concentration of red blood cells in the neonate
more fragile than normal + less developed liver function
= break down more rapidly = releasing lots of bilirubin
usually excreted via placenta, after birth - rise in bilirubin shortly after birth
45
how does neonatal jaundice present
mild yellowing of skin and sclera from 2 – 7 days of age
46
what are increased production of bilirubin causes of neonatal jaundice
Haemolytic disease of the newborn
ABO incompatibility
Haemorrhage
Intraventricular haemorrhage
Cephalo-haematoma
Polycythaemia
Sepsis and disseminated intravascular coagulation
G6PD deficiency
47
what are decreased clearance of bilirubin causes of neonatal jaundice
Prematurity
Breast milk jaundice
Neonatal cholestasis
Extrahepatic biliary atresia
Endocrine disorders (hypothyroid and hypopituitary)
Gilbert syndrome
48
when is neonatal jaundice pathological
Jaundice in the first 24 hours of life
= urgent investigations and management
common cause = sepsis
49
what are causes of jaundice in first 24hrs
rhesus haemolytic disease
ABO haemolytic disease
hereditary spherocytosis
glucose-6-phosphodehydrogenase
50
what is kernicterus
brain damage due to high bilirubin levels.
51
when is jaundice prolonged
More than 14 days in full term babies
More than 21 days in premature babies
52
what are causes of prolonged jaundice in newborns
biliary atresia
hypothyroidism
galactosaemia
urinary tract infection
prematurity
53
how is newborn jaundice investigared
FBC and Blood film
conjugated bilirubin
blood type testing
direct coombs test
thyroid function
blood and urine cultures
G6PD levels
54
how is the decision to start treatment for neonatal jaundice decided
total bilirubin levels are monitored and plotted on treatment threshold charts
x axis = age of the baby (hours)
y axis = total bilirubin level
if bilirubin reaches threshold = commence treatment
55
what is the treatment for neonatal jaundice
Phototherapy
Extremely high = exchange transfusion
56
how does phototherapy work
converts unconjugated bilirubin into isomers that can be excreted in the bile and urine without requiring conjugation in the live
blue light is best
Once phototherapy is complete, a rebound bilirubin should be measured 12 – 18 hours after stoppin
57
how does Kernicterus present
less responsive, floppy, drowsy baby with poor feeding
permeant damage --> cerebral palsy, learning disability + deafness
58
What is Necrotising enterocolitis
part of the bowel becomes necrotic
in premature neonates
life threatening
59
what can untreated Necrotising enterocolitis lead to
lead to bowel perforation. Bowel perforation leads to peritonitis and shock.
60
what are 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
61
how does Necrotising enterocolitis present
feeding intolerance
abdominal distension
bloody stools
Absent bowel sounds
vomiting
62
what is investigation of choice for Necrotising enterocolitis
Abdo Xray
63
what are blood tests for Necrotising enterocolitis
Full blood count for thrombocytopenia and neutropenia
CRP for inflammation
Capillary blood gas will show a metabolic acidosis
Blood culture for sepsis
64
what would XRay show for Necrotising enterocolitis
- Dilated loops of bowel
- Bowel wall oedema (thickened bowel walls)
- Pneumatosis intestinalis is gas in the bowel wall and is a sign of NEC
- Pneumoperitoneum is free gas in the peritoneal cavity and indicates perforation
- Gas in the portal veins
65
what is the management for Necrotising enterocolitis
stabilize = nil by mouth with IV fluids, total parenteral nutrition (TPN) and antibiotics
Ng tube to drain fluid and gas from stomach and inesteine
surgical emergency = remove the dead bowel tissue
66
what are complications of Necrotising enterocolitis
Perforation and peritonitis
Sepsis
Death
Strictures
Abscess formation
Recurrence
Long term stoma
Short bowel syndrome after surgery
67
what is neonatal hypoglycaemia
< 2.6 mmol/L
68
what can cause persistent/severe hypoglycaemia after birth
preterm birth (< 37 weeks)
maternal diabetes mellitus
IUGR
hypothermia
neonatal sepsis
inborn errors of metabolism
nesidioblastosis
Beckwith-Wiedemann syndrome
69
how does hypoglycaemia present in neonates
may be asymptomatic
'jitteriness'
irritable
tachypnoea
pallor
poor feeding/sucking
weak cry
drowsy
hypotonia
seizures
70
how is asymptomatic hypoglycaemia managed in neonates
encourage normal feeding (breast or bottle)
monitor blood glucose
71
how is symptomatic hypoglycaemia managed in neonates
admit to the neonatal unit
intravenous infusion of 10% dextrose
72
when is Meconium aspiration syndrome most common
post-term deliveries, with rates of up to 44% reported in babies born after 42 weeks.
73
What are RF for Meconium aspiration syndrome
maternal hypertension, pre-eclampsia, chorioamnionitis, smoking or substance abuse.
74
how common is cleft lip and palate
1 in every 1,000 babies
75
what fails to fuse in cleft lip
fronto-nasal and maxillary processes
76
what dails to fuse in cleft palate
palatine processes and the nasal septum
77
what are problems associated with having Cleft lip and palate
feeding: orthodontic devices may be helpful
speech: with speech therapy 75% of children develop normal speech
increased risk of otitis media for cleft palate babies
78
how is Cleft lip and palate managed
lip repaired first before 3 months
then palate in 6-12 months
79
what are TORCH infections
Toxoplasmosis
Others (syphilis, hepatitis B)
Rubella
Cytomegalovirus
Herpes simplex
80
what is Gastroschisis
birth defect where there is a hole in the abdominal (belly) wall beside the belly button.
This results in the baby's intestines extending outside of the baby's body
81
in pregnancy what thryoid hormone increases
thyroxine-binding globulin (TBG).
= increase in total thyroxine but not free thyroxine
82
what can Untreated thyrotoxicosis cause
increases the risk of fetal loss, maternal heart failure and premature labour
83
how is maternal hyperthyroid managed
1st trimester = Propylthiouracil
2nd trimester = carbimazole
84
what is checked in pregnancy at 30-36 weeks to help determine the risk of neonatal thyroid problem
thyrotrophin receptor stimulating antibodies
85
what is Abx of choice for GBS prophylaxis
benzylpenicillin
86
when are swabs for GBS offered
35-37 weeks or 3-5 weeks before delivery date
87
what are fluid requirements for children for the first 10kg
100ml/kg
88
what are fluid requirements for children 10-20kg
100ml/kg for first 10kg
+ 50ml/kg for each addition 1kg of weight between 10kg - 20kg
89
what are fluid requirements for children over 20kg
100ml/kg for each kg for first 10kg
+ 50ml/kg for each addition 1kg of weight between 10kg - 20kg
+ 20ml/kg for each 1kg of body weight over 20kg
90
what is max fluid requirment
2L for girls 2.5 L for boys
91
what is school exclusion for scarlet fever
24 hours after commencing antibiotics
92
what is school exclusion for whooping cough
2 days after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics )
93
what is school exclusion for measles
4 days from onset of rash
94
what is school exclusion for rubella
5 days from onset of rash
95
what is school exclusion for chickenpox
All lesions crusted over
96
what is school exclusion for mumps
5 days from onset of swollen glands
97
what is school exclusion for D&V
Until symptoms have settled for 48 hours
98
what is school exclusion for impetigo
Until lesions are crusted and healed, or 48 hours
after commencing antibiotic treatment
99
what is school exclusion for scabies
Until treated
100
what is school exclusion for influenza
Until recovered
101
how does Oesophageal atresia present
choking and cyanotic spells following aspiration
102
what are characteristic features of congenital Rubella
Sensorineural deafness
Congenital cataracts
Congenital heart disease (e.g. patent ductus arteriosus)
Glaucoma
103
what are characteristic features of congenital Toxoplasmosis
Cerebral calcification
Chorioretinitis
Hydrocephalus
104
what are characteristic features of congenital Cytomegalovirus
Low birth weight
Purpuric skin lesions
Sensorineural deafness
Microcephaly
