Neonatology Flashcards
Which antibody is responsible for passive immunity in newborn?
IgG can cross placenta and via breast milk
What causes RDS?
Ineffective / inadequate surfactant
Prematurity <32w
MAS
Hypoxia
Hypothermia
Maternal DM
Signs of RDS on CXR
- Generalised atalectasis - ground glass appearance
- Air bronchograms
- Reduced lung vol
Define bronchopulmonary dysplasia (CLD)
Persistent o2 requirement after 28 days of life or 36+0 corrected
Risk factors for BPD
PREMATURITY
Infection
Ventilatory support
Male
Caucasian
IUGR
FHx asthma
PDA
Maternal smoking / HTN
Signs of BPD on CXR
- Diffuse interstitial shadowing
- Hyperexpansion
- Flattening of diaphragm
- Cysts
- Bronchial wall thickening
Treatment of BPD
- Prevention: AN steroids
- Supportive - nutrition, resp. support
- Steroids
- Diuretics
Presentation of Choanal Atresia
- Cyanosis / resp. distress on feeding, improves on crying
- Minimal ventilation requirement
- Ix - NGT into both nostrils
Conditions associated with Choanal Atresia
Down’s
Treacher Collins
CHARGE
Treatment of pneumothorax in neonate
- Increased o2 concentration
- Needle thoracocentesis
- Chest drain
Signs of TTN on CXR
- Cardiomegaly
- Pleural effusion / fluid in horizontal fissure
- Prominent peri-hilar interstitial markings
Signs of MAS on CXR
- Heterogenous opacification (collapse and consolidation)
- Over-inflation
- Atalectasis
- +/- Pneumothorax
Treatment of MAS
- Intubation and ventilation ?Oscillation
- Surfactant
- Inotropes
- NO
- ECMO
CXR appearance in PPHN
Dark (reduced pulmonary blood flow)
Risk factors for PPHN
Perinatal asphyxia
MAS
RDS
EONS
Polycythaemia
Acidosis, hypothermia, hypoglycaemia
NSAIDs, SSRIs
Pulm. hypoplasia
CDH
Indication for ECMO in PPHN
Oxygenation index >30 for >4 hours
OI = (FiO2 x MAP) / Post-ductal PaO2
Common pathogens for congenital pnuemonia
- Gram -ve: E. Coli, klebsiella, pseudomonas
- GBS
- Staph
Causes of pulmonary hypoplasia
- Oligohydramnios
- CDH
- Decreased breathing activity - Werdnig Hoffman
Pulmonary hypoplasia CXR
Dense
Hypoinflated
“Bell shape”
What are VACTRL associations?
Vertebral defects
Anorectal malformation
Cardiac defect
TOF-OA
Renal anomalies
Limb defects
(Not genetic). Associated with maternal progesterone.
What is a bronchopulmonary sequestration?
Normal lung tissue.
Supplied by systemic circulation not pulmonary
Not connected to pulmonary tree
Causes of neonatal seizures
- Cerebral malformation
- HIE
- Infection
- Metabolic - pyridoxine def.
- IVH
- Hypoglycaemia / electrolyte disturbance
- Neonatal abstinence syndrome
- CVA
Treatment escalation of neonatal seizures
- Phenobarbital 20mg/kg
- Phenobarbital 10mg/kg
- Phenobarbital 10mg/kg
- Phenytoin 20mg/kg
- Clonazepam / Midazolam 100mcg/kg
- Lidocaine 2mg/kg
3 types of perinatal stroke
- Arterial ischaemic stroke (most MCA)
- Haemorrhage
- Cerebral sinovenous thrombus
Grading of IVH
- Bleeding in germinal matrix
- 1+ bleeding into ventricle
- 2+ ventricular dilatation
- 3+ Bleeding extending beyond ventricles
Most likely site of IVH in pre-term and term babies
- Pre-term = Germinal matrix
- Term = Choroid plexus
Criteria for Dx of HIE
- Evidence of intrapartum asphyxia
- Respiratory depression at delivery
- Encephalopathy in the immediate postnatal period
Indicators of Mod - Severe HIE
Early onset seizures
Unresponsive
Hypotonic
Abnormal primitive reflexes
Abnormal EEG
Risk factors for ROP
BW <1kg (screen <1.5kg)
Gestation <32 weeks
Hyperoxygenation
Acidosis
–> screening <32/40 or <1kg
Treatment ROP
Anti-VEGF injections
Laser ablation in severe ROP
Presentation of PDA
Systolic machinery murmur LUSE –> back
Bounding pulses
Heart failure
Pulmonary haemorrhage
Hypotension (wide pulse pressure)
Poor growth, feeding difficulty
Risk: IVH, NEC
Treatment PDA
Conservative (2/3 close spont)
Fluid restriction / diuretics
Paracetamol ( reduced prostaglandins)
Ibuprofen (COX inhibitor)
Surgical ligation
Presentation of NEC
More in preterm
Tender, distended abdo
Bilious vomiting
Bloody stool
Sign of NEC on AXR
Pneumatosis (intramural nitrogen + hydrogen)
Risk factors for NEC
Prematurity
IUGR (esp absent EDF)
Hypoxia
Polycythaemia
Exchange Tx
Rapid increase in feeds
Low IgA levels (more in breast milk)
NEC histology
- Necrosis and microthrombus
- Patchy mucosal ulceration
- Oedema and haemorrhage
NEC treatment
- NBM 10-14d
- Triple Abx - BenPen, Gent, Met
- Systemic support
- ?Surgical intervention - deterioration, perforation, obstruction
Risk factors for transient hypoglycaemia in newborn
- Hyperinsulinism in utero - maternal DM, LGA
- Low glycogen stores - LBW, IUGR
- Increased requirements - sepsis, hypothermia, Rh disease
Causes of refractory hypoglycaemia in neonate
CAH
Inborn erros of metabolism
Glycogen deficiency
Hypopituitarism
Hyperinsulinism
Beckwith-wiedemann
Rh haemolytic disease
Treatment of persistent neonatal hypoglycaemia
- Reduced insulin secretion - diazoxide, octreotide, (pancreatic resection)
- Increase glucose delivery - fluids, glucagon.
Cause of metabolic bone disease in neonates
Substrate deficiency (PO4-, Ca2+, Vit D) –> poor bone mineralisation
RF: Prolonged TPN/ diuretics, breastfed
Diagnosing metabolic bone disease
Low phosphate
High calcium
High Alk Phos
X-rays - Cupping, osteoporosis, fractures
Sx: Reduced linear growth, fractures
Treatment metabolic bone disease
PO Phosphate
TPN - 2 mmol/kg/day calcium, 2.5 mmol/kg/day phosphate
Prevent with PO Vit D
What is Haemorrhagic disease of the newborn?
Life threatening bleeding in newborn.
Due to low levels of Vit K dependent clotting factors at birth (II, VII, IX, X)
Treatment Haemorrhagic disease of newborn
IV Vit K
FFP
Blood groups for Rh haemolytic disease
Rh +ve foetus
Rh -ve mother
Presentation of Rh haemolytic disease
Foetal anaemia / hydrops
Early severe jaundice
Blueberry muffin rash
Hepatosplenomegaly
Coagulopathy/ thrombocytopenia
Leucopenia
ABO incompatibility presentation / Tx
Jaundice <24 hours
Usually less severe than Rh incompatibility
Tx: PTx, IVIg. Rarely needs exchange transfusion.
Features of Foetal Alcohol Syndrome
- Microcephaly
- Cognitive impairment / GDD
- Abnormal corpus collosum
- Dysmorphic - short palpebral fissure, smooth philtrum, cleft palate, micrognathia, thin lip
- VSD
- Joint abnormalities
Which medications in pregnancy are teratogenic?
- Valproate - NTD, cleft
- Phenytoin/ carbamazepine - IUGR, GDD, limb and finger deformities
- Nicotine- IUGR, LD
- Alcohol
- Warfarin - Nasal hypoplasia, chloanal atresia
- Thalidomide
- Isotretanoin - craniofacial, cardiac, CNS
- Methotrexate - microcephaly, NTD, short limbs
Time of onset for different substances for NAS
- Short time after birth = Opiods, SSRIs
- Long = BDZ
Which maternal substance abuse requires avoiding breast feeding?
Methadone
Amphetamines
Cocaine
Central causes for “floppy baby” (preserved strength)
- Acute: HIE, infection, ICH, drugs
- Chronic: Chromosomal eg Down’s, Prader-Willi, structural cerebral
- Inborn errors of metabolism
- Spinal cord birth trauma
Peripheral causes for “floppy baby” (weak and floppy) by location
- Ant. horn cell: SMA
- NMJ: Transient / congenital myaesthenia, infantile botulism
- Peripheral n: Guillain-Barre, demyelinating / hypomyelinating neuropathy
- Muscle: Myopathies, muscular dystrophies, myotonic dystrophy, hypothyroidism, glycogen storage disorders
- CT: Marfan, Ehler’s Danlos, Oestogenesis imperfecta
What causes transient neonatal myasthenia gravis?
Transplacental acetylcholine receptor antibodies
Genetics and presentation of myotonic dystrophy in neonate
- Autosomal dominant, trinucleotide repeats DMPK gene Ch 19 –> anticipation
- Hypotonia
- Polyhydramnios / RDS
- Parent - unable to loosen grip/ open eyes.
- Myopathic face.
Which condition is there a risk of malignant hyperthermia with analgesia?
Myotonic dystrophy
Causes of Hydrops Foetalis
- Haemolytic disease
- Genetic - Trisomies, Noonan’s, Turner’s
- Foetal anaemia - TTTS, alpha thalassaemia
- Infection- Parvovirus B19, TORCH
- Cardiac - Structural, arrhythmia, cardiomyopathy
- Cystic hygroma
- Malformation - CPAM, Bowel atresia
- Idiopathic
Hydrops treatment
- Antenatally - Blood Tx, Tx SVT, laser ablation TTTS
- Supportive
- Chest / ascitic drain
- Octreotide for chylothorax / ascites
Pathogens that cause early-onset neonatal sepsis (<48 hours)
- GBS
- Gram negative organisms
- Staph
- Listeria monocyotogenes
- Klebsiella
- Pseudomonas
Pathogens that cause late-onset neonatal sepsis (>48 hours)
- GBS
- Coagulase negative staphylococcus eg preterms with lines
ABx - Fluclox and Gent
Presentation of Congenital HSV infection
- Vesicular rash
- Conjunctivitis
- Encephalitis
- Systemic: Shock, respiratory failure, deranged clotting
Presentation of congenital syphyillis
- Fever
- Irritability
- Saddle nose
- Rashes / ulceration
Presentation congenital listeria
- Preterm
- Delayed meconium
Risk = soft cheese and unpasturised milk
Maternal Hep B: Indications for treatment at birth
- HBsAg positive –> Hep B vaccine
- e-antigen +ve or e-antibody negative –> Hep B Ig
Indications for and treatment in maternal VZV
- Varicella zoster immunoglobulin if maternal infection <7 days before or <4 days after delivery
Presentation of infant of mother with VZV in pregnancy
- If in first half of pregnancy –> affect dev of that dermatome. Aysmmetrical.
- Skin / digital dysplasia
- Ocular
- Neuro damage / GDD
- Bladder/ bowel dysfunction
Presentation of congenital toxoplasmosis
Protozoal infection
- Cerebral calcification
- Hydrocephalus
- Chorioretinitis
(Risk = raw meat, cat faeces)
Presentation of congenital CMV
- Microcephaly
- Hepatosplenomegaly
- IUGR - symmetrical
- Cardiac defects
- Jaundice
- Petechiae
- CrUSS - periventricular calcification
- Seizures
- Childhood SN hearing loss
Presentation of congenital rubella infection
If in 1st trimester –> 80% congenital anomalies
- Cataracts
- SN Deafness
- CHD - PDA, pulm. stenosis
- Rash
- Microcephaly
- GDD
Hearing screening tests in newborns
- Automated otoacoustic emission test (vibrations of basilar membrane)
- Repeat 1
- Automated auditory brainstem response - records neuro activity in response to noise. More accurate.
What conditions are screened for on D5 blood spot test?
- Sickle cell disease
- CF
- Congenital hypothyroid
- 6 metabolic diseases - PKU, MCADD, maple syrup urine disease, isovolaemic acidaemia, glutaric aciduria type 1, homocystinuria
- +/- SCID
What conditions are associated with duodenal atresia?
Down’s
Prader Willi
Presentation of duoedenal atresia
Polyhydramnios
Early bilious vomiting
USS - ‘double bubble’
Presentation of Exomphalos
Herniation of abdominal organs outside body, covered in sac
Associated with trisomies
RF for gastroschisis
Young Mum
Smoking
Drugs
Low SES.
Most common type of TOF?
Type C - Oesophageal atresia with TOF to distal oesophageal segment
Presentation TOF
- Polyhydramnios
- Choking / coughing/ cyanosis during feeding
- Oral secretions ++
Complications of TOF-OA repair
Anastamotic leak
Strictures
GOR
Recurrent cough
Bronchitis
LRTI
Presentation of CDH
- Polyhydramnios
- Cardio-mediastinal shift
- Inability to demonstrate stomach bubble
- Scaphoid anterior wall.
- Bochdalek hernia (most common) = left posterolateral defect in diaphragm wall
- Significant resp. distress.
Management CDH
NO BVM VENTILATION
Intubation
Gastric decompression
Support - correct acidosis, Tx PPHN
+/- surfactant
Surgery
What is Kernicterus?
Bilirubin induced encephalopathy. Caused by bilirubin not bound to albumin –> staining and necrosis
Factors that increased risk for bilirubin neurotoxicity
- High bilirubin
- Low albumin
- Drugs which displace bili: ceftriaxone, ibuprofen
- Disruption of BBB eg HIE, seizures, meningitis
- Acidosis
- Hyperosmolality –> increased BF to brain
Long term effects of Kernicterus
Choreoathetoid CP
SN hearing loss
Upward gaze abnormality
Dental enamel dysplasia
Breakdown of Hb by the reticuloendothelial system can be determined by measurement of which exhaled gas?
Carbon Monoxide
What substances are created for excretion when conjugated bilirubin is hydrolysed in the gut?
Sercobilinogen –> Faeces
Urobilinogen –> urine
What are the 3 mechanisms for jaundice in neonates?
- Increased RBC turnover eg polycythaemia, haemolysis, G6PD def
- Delayed bilirubin clearance eg delayed meconium
- Conjugated hyperbilirubinaemia eg obstruction due to biliary atresia
Differentials for Jaundice <24 hours of age
- Haemolysis - Rhesus / ABO incompatibility
- Sepsis
Presentation Crigler-Najjar syndrome
AR
Congenital unconjugated jaundice
Define polycythaemia and what is the threshold to treat?
Haematocrit >65%
Treated if >70% - liberal fluids +/- exchange transfusion
Jaundice investigations in neonate
- TCB / SBR
- FBC/ Film/ Haematocrit
- ?Septic screen
- Blood group and DAT
-?G6PD levels
Differentials for neonatal conjugated hyperbilirubinaemia
CAMOF(L)AGED
Congenital infection
Acquired infection
Metabolic
Obstructive - BA, choledochal cyst
Flow - CF, Alagille syndrome
Alpha-1-antitrypsin
General - Unwell, Prem
Endocrine - Hypothyroid, hypopituitary
Drugs - TPN
Oxygenation is dependent on MAP. How is MAP calculated?
MAP = PEEP + [(PIP-PEEP) x(Ti/Total respiratory cycle)]
Ventilation adjustments to improve CO2 clearance
- Suctioning / reducing dead space
- Increase Rate
- Increase PIP, reduce PEEP
- Increase VG
Ventilation adjustments to increase oxygenation
- Increase FiO2
- Increase PEEP / PIP
- Increase Ti
- Consider muscle relaxant
- Consider Surfactant
- Patient triggered ventilation
Minute volume calculation
MV = Tidal volume x Respiratory Rate
Causes of physiological jaundice
Multifactorial.
Immature liver with low levels of UDGT
Unconjugated hyperbilirubinaemia.
Low concentrations of ligandin
High red cell mass with shortened life span.
Increased enterohepatic circulation
Risk to newborn in mother with SLE
Heart block
Anti-Ro/ La Abs can damage conduction system of foetal heart.
NB ECG
Also thrombocytopenia, cutaneous malformation
What is Potter Sequence?
- Sequence of congenital anomalies. NOT genetic. Secondary to oligohydramnios of other cause
- Oligohydramnios
- Severe pulm. hypoplasia –> resp distress
- PUV, small kidneys/ renal agenesis
- Clubbed feet
- Cardiac anomalies
- Facial anomalies: Low-set ears, beaked nose, micrognathia
Presentation of Posterior-urethral valves
- BOYS
- Oligohydramnios, hyronephrosis AN
- Depending on severity, pulmonary hypoplasia
- Oligouria
Complications of Posterior urethral valves
VUR
Hydronephrosis
Renal failure
Renal dysplasia
UTIs
Bladder dysfunction
Maternal Cocaine - presentation of baby
- IUGR
- Microcephaly
- CrUSS - subependymal haemorrhage and cysts.
- Behavioural probs later
Maternal gonorrhoea, presentation in baby and treatment
- Bilateral conjunctivitis, profuse purulent discharge
- MC&S: Gram negative diplococci
- Tx: IV BenPen
Presentation congenital Chlamydia and Tx
- Neonatal pneumonitis
- Bilateral purulent conjunctivitis (D5-14)
- +/- Middle ear infection.
- Ix: Raised IgG, IgA and IgM, high eosinophils
- Tx conjunctivitis: Oral erythromycin. 12.5mg/kg every 6 hours for 2 weeks.
Insulinoma biochemistry
- Hypoglycaemia
- High insulin
- High c-peptide (endogenous)
Hypercarbic stimulus used to establish brain stem death in testing in neonates
PaCo2 >8.0kPa
Criteria to confirm brainstem death
- Absent brainstem reflexes – pupillary, corneal, vetibulo-ocular reflex, gag and cough reflexes
- Absent motor response to pain (supraorbital pressure)
- Absent respiratory response to rise in arterial blood pressure of CO2.
Genetic defect retinoblastoma?
RB1 tumour-suppressor gene
What is SIPPV? (PCAC)
Synchronised intermittent positive pressure ventilation
Every breath is assisted and additional breaths given if breathing below back up rate.
What is volume guarantee?
Ventilator will adjust the pressures delivered to provide desired vol air to lungs.
Auto-weaning, as lung compliance reduces, pressures will drop.
What is SIMV?
= Synchronised intermittent mandatory ventilation
Ventilator will give a certain number of breaths synchronising with the patients breathing. Doesn’t support breaths above back up rate.
Causes of oligohydramnios
- Abnormal renal function eg PUV, hydronephrosis, Potter Sequence
- ROM
- Placental insufficiency
- TTTS
Causes of polyhydramnios
- GDM
- TOF-OA
- Neuromuscular disorder affecting swallow
- Bowel obstruction eg atresia, annular pancreas
- Infection eg CMV
Differentials for baby with protruding tongue
- Down’s
- Congenital hypothyroid
- Beckwith-Wiedemann
- Mucopolysaccharide syndrome
Erb’s palsy - nerve roots and presentation
C5,6
“Tip waiter”
- Arm adduction, internal rotation, forarm pronation, wrist flexion.
- Able to grasp, other arm reflexes absent
Klumpke’s palsy - Nerve roots and presentation
C8, T1
- “Claw hand”
- Weak intrinsic muscles of hand
- Grasp absent, all other arm reflexes present
Total brachial plexus palsy nerve roots and presentation
C5 - T1
Limp arm, all reflexes absent
Brachial plexus injury at birth - Ix and Mx
Ix: CXR ?fracture ?diaphragmatic palsy
Mx: Surgery –> Nerve conduction studies / MRI
Causes of neonatal thrombocytopenia
IUGR / preterm
Sepsis / DIC
Asphyxia
Alloimmune thrombocytopenia
Viral infections - CMV, HSV
AI
Most common causes of meconium ileus
CF (90%)
Hypothyroidism
Symptoms of Gastro-oesophageal reflux
Regurgitation / vomiting
Feeding difficulty / irritability
Back arching
Cough / wheeze
Hoarse voice
ABCs
Chest pain
