Neonatology

Question 1

What is a caput succedaneum?

Answer 1

oedema collecting on the scalp, outside the periosteum
caused by pressure to the scalp during a traumatic, prolonged or instrumental delivery
OUTSIDE the periosteum -> ABLE to cross suture lines
resolves within a few days

Question 2

What is a cephalhematoma?

Answer 2

haematoma between the skull and the periosteum
aka traumatic subperiosteal haematoma
INSIDE the periosteum -> DOES NOT cross suture lines
resolves within a few months
can cause anaemia and jaundice depending on size

Question 3

Caput succedaneum vs cephalhematoma?

Answer 3

Caput succedaneum can cross suture lines as it is outside the periosteum, successfully resolves within few days

cephalhematoma is below the periosteum and therefore does not cross suture lines, successfully resolves within few months
risk of anaemia and jaundice

Question 4

What is Erb’s palsy?

Answer 4

‘waiters tip’ appearance
internally rotated shoulder
extended elbow
pronated flexed wrist
lack of movement in affected arm

C5/C6 nerve roots in the brachial plexus

Question 5

Presentation of fractured clavicle?

Answer 5

lack of movement
asymmetry of movement
asymmetry of shoulders
pain and distress on movement of the arm

Question 6

Fractured clavicle risk factors?

Answer 6

shoulder dystocia
traumatic or instrumental delivery
large birth weight

Question 7

Common birth injuries?

Answer 7

caput succedaneum
cephalohematoma
subgaleal haemorrhage
Erb’s palsy
Klumpke’s palsy
clavicle #

Question 8

Common organisms causing neonatal sepsis?

Answer 8

GBS
E coli
Listeria
Klebsiella
Staph aureus

Question 9

RFs for neonatal sepsis?

Answer 9

GBS colonisation
GBS sepsis in prev baby
maternal sepsis
chorioamnionitis
maternal fever > 38
prematurity
PPROM
PROM

Question 10

Presentation of neonatal sepsis?

Answer 10

fever
hypotonia
poor feeding
respiratory distress
apnoea
vomiting
tachycardia or bradycardia
hypoxia
jaundice in first 24hrs
seizures
hypoglycaemia

Question 11

Red Flags for neonatal sepsis?

Answer 11

confirmed or suspected maternal sepsis
signs of shock
seizures
term baby needing mechanical ventilation
respiratory distress starting >4hrs after birth
sepsis in another baby in multiple pregnancy

Question 12

Neonatal sepsis management?

Answer 12

Start Abx if two or more features/RFs or if one RED FLAG
Start Abx within 1hr of decision
Blood cultures before Abx
baseline FBC and CRP
LP

benzylpenicillin + gentamicin

Question 13

When to stop Abx in neonatal sepsis?

Answer 13

baby is clinically well, blood cultures are negative for 36hrs after taking them and 2 CRPs are <10

Question 14

Causes of hypoxic-ischaemic encephalopathy?

Answer 14

anything that leads to asphyxia

maternal shock
intrapartum haemorrhage
prolapsed cord
nuchal cord

Question 15

Grading of HIE?

Answer 15

Sarnat Staging

Mild -> poor feeding, irritability, hyperalert
normal prognosis, resolves within 24hrs

Moderate -> poor feeding, hypotonic, lethargic, seizures
can take weeks to resolve, up to 40% develop CP

Severe -> red. consciousness, apnoeas, flaccid, reduced or absent reflexes
up to 50% mortality
up to 90% develop CP

Question 16

Mx of HIE?

Answer 16

NICU
supportive care (resuscitation, ventilation, circulatory support, nutrition, acid-base balance, treatment of seizures)
therapeutic hypothermia

follow up with MDT for lasting brain damage

Question 17

What is therapeutic hypothermia?

Answer 17

active cooling to 33-34 degrees for 72 hours using cooling blankets and a cooling hat
aim is to reduce inflammation and neurone loss after the acute hypoxic injury
reduces long-term risks of CP, developmental delay, learning disability, blindness and death

Question 18

Causes of neonatal jaundice?

Answer 18

Incr. production:
haemolytic disease
ABO incompatibility
haemorrhage
IVH
cephalohematoma
polycythaemia
sepsis and DIC
G6PD deficiency

Red. excretion:
prematurity
breast milk jaundice
neonatal cholestasis
extrahepatic biliary atresia
endocrine disorders
Gilbert syndrome

Question 19

What is prolonged jaundice?

Answer 19

more than 14 days in term babies
more than 21 days in prem babies

Question 20

Causes of prolonged jaundice?

Answer 20

biliary atresia
hypothyroidism
G6PD deficiency

Question 21

Investigations for neonatal jaundice?

Answer 21

FBC and blood film
bilirubin (conjugated and unconjugated)
blood type testing
Direct Coombs test
thyroid function
blood culture
G6PD levels

Question 22

Mx of neonatal jaundice?

Answer 22

plot bilirubin levels on treatment threshold charts
phototherapy
IVIG in haemolysis
exchange transfusions v rare

Question 23

What is kernicterus?

Answer 23

complication of neonatal jaundice as unconjugated bilirubin can cross the BBB and cause brain damage

results in CP, learning disabilities and deafness

Question 24

Classifying prematurity?

Answer 24

<28wks - extreme preterm
28-32wks - very preterm
32-37wks - moderate to late preterm

Question 25

Associations with prematurity?

Answer 25

social deprivation
smoking
alcohol
drugs
over or underweight mother
maternal co-morbidities
multiple pregnancy
FHx of prematurity

Question 26

Mx of prematurity pre-birth?

Answer 26

tocolysis with nifedipine
maternal corticosteroids
IV magnesium sulphate
delayed cord clamping or cord milking

Question 27

Complications of prematurity?

Answer 27

early:
respiratory distress syndrome
hypothermia
hypoglycaemia
poor feeding
apnoea or bradycardia
neonatal jaundice
IVH
retinopathy of prematurity
NEC
immature immune system and infections

late:
CLDP
learning disabilities
behavioural issues
susceptibility to infections, particularly resp
hearing and visual impairment
CP

Question 28

Mx of apnoea of prematurity?

Answer 28

apnoea monitors
tactile stimulation
IV caffeine

Question 29

What is retinopathy of prematurity?

Answer 29

retinopathy caused by abnormal development of blood vessels in the retina due to oxygen exposure too early
results in scarring, retinal detachment and blindness

Question 30

Screening for retinopathy of prematurity?

Answer 30

performed by an ophthalmologist
30-31wks gestational age for babies <27wks
4-5wks of age in babies >27wks
screening every 2 weeks until retinal vessels enter zone 3

Question 31

Tx of retinopathy?

Answer 31

transpupillary laser photocoagulation to halt and reverse neovascularisation

cryotherapy
intravitreal VEGF inhibitors
Sx if retinal detachment occurs

Question 32

RDS appearance on CXR?

Answer 32

‘ground-glass’ appearance

Question 33

What causes respiratory distress syndrome?

Answer 33

lack of surfactant in the premature lungs leads to an increase in surface tension within the alveoli -> inadequate expansion of the lungs and inadequate gaseous exchange resulting in hypoxia, hypercapnia and respiratory distress

Question 34

Mx of RDS?

Answer 34

antenatal maternal steroids
intubation and ventilation
supplementary O2
CPAP
ET surfactant

Question 35

Complications of RDS?

Answer 35

Early:
pneumothorax
infection
apnoea
IVH
pulmonary haemorrhage
NEC

Late:
CLDP
retinopathy of prematurity
neurological, hearing and visual impairment

Question 36

What is necrotising enterocolitis?

Answer 36

NEC
disorder affecting premature neonates where part of the bowel becomes necrotic
life-threatening illness as can cause perforation, peritonitis and shock

Question 37

RFs for NEC?

Answer 37

prematurity
low birth weight
formula feeding
RDS and assisted ventilation
sepsis
PDA and other congenital heart disease

Question 38

Presentation of NEC?

Answer 38

intolerance to feeds
vomiting, green bile
unwell
distended, tender abdomen
absent bowel sounds
blood in stools
features of peritonitis and shock

Question 39

Investigations for NEC?

Answer 39

Bloods:
FBC (neutropenia, thrombocytopenia)
CRP
blood gas (metabolic acidosis)
blood culture

PFA

Question 40

Features of NEC on PFA?

Answer 40

dilated loops of bowel
bowel wall oedema
pneumatosis intestinalis (pathognomonic)
pneumoperitoneum (perforation)
gas in portal veins

Question 41

Mx of NEC?

Answer 41

nil by mouth with IV fluids, TPN and antibiotics
NG tube can be used to drain ‘drip and suck’
surgical emergency

Question 42

Complications of NEC?

Answer 42

perforation
peritonitis
shock
death
sepsis
strictures
abscess formation
recurrence
long-term stoma
short bowel syndrome

Question 43

Substances which cause neonatal abstinence syndrome?

Answer 43

opiates
methadone
benzos
cocaine
amphetamines
nicotine
cannabis
alcohol
SSRIs

Question 44

What is neonatal abstinence syndrome?

Answer 44

presence of withdrawal symptoms in a neonate following birth due to consumption of substances by the mother during the pregnancy

Question 45

Signs and symptoms of neonatal abstinence syndrome?

Answer 45

CNS:
irritability
incr. tone
high pitched cry
not settling
tremors
seizures
Resp:
yawning
sweating
unstable temperature
tachypnoea
GI:
poor feeding
regurgitation or vomiting
hypoglycaemia
loose stools and sore nappy area

Question 46

Mx of neonatal abstinence syndrome?

Answer 46

monitoring in neonates of mothers with known addictions
quiet and dim environment with gentle handling
medical mx if severe (morphine sulphate for opiates, phenobarbitone for non-opiates)

support mother to stop
consider social services
check breastfeeding suitability

Question 47

Foetal alcohol syndrome features?

Answer 47

microcephaly
thin upper lip
smooth philtrum
short palpebral fissures
learning disability
behavioural difficulties
hearing and vision
CP

Question 48

Congenital rubella syndrome features?

Answer 48

congenital cataracts
congenital heart disease (PDA, pulmonary stenosis)
learning disability
hearing loss

Question 49

Congenital varicella syndrome features?

Answer 49

fetal growth restriction
microcephaly
hydrocephalus
learning disability
limb hypoplasia
scars and skin differences along dermatomes
chorioretinitis

Question 50

Congenital CMV features?

Answer 50

fetal growth restriction
microcephaly
hearing loss
vision loss
learning disability
seizures

Question 51

Congenital toxoplasmosis features?

Answer 51

intracranial calcification
hydrocephalus
chorioretinitis

Question 52

Minimising the risk of SIDS?

Answer 52

baby on their back
head uncovered
feet at foot of bed
keep cots clear of toys and blankets
maintain room temp between 16 and 20
avoid smoking
avoid co-sleeping
if co-sleeping avoid alcohol, drugs, sleeping tablets or deep sleepers

Question 53

Features of APGAR score?

Answer 53

Appearance (skin colour)
Pulse
Grimace
Activity
Respiration

/10 - 2 for each
assess at 1, 5 and 10 mins

Question 54

Principles of neonatal resuscitation?

Answer 54

warm the baby
calculate APGAR score
stimulate breathing
inflation breaths (2 cycles of 5 breaths)
chest compressions
avoid delayed cord clamping (resuscitation takes priority)

Question 55

Immediate care after birth?

Answer 55

skin to skin
clamp umbilical cord (wait 1 minute)
dry the baby
keep baby warm
Vit K
label
measure weight and length

Question 56

Heelprick test tests for?

Answer 56

9 congenital conditions, day 5

galactosaemia
ADA severe combined immunodeficiency
cystic fibrosis
congenital hypothyroidism
phenylketonuria
maple syrup urine disease
glutaric aciduria type 1
homocystinuria
medium-chain acyl-COA dehydrogenase deficiency

Question 57

Barlow and Ortolani tests?

Answer 57

Barlow - testing for dislocation:
flex hip to 90
apply posterior force through femur and gently adduct thigh
pressure onto the knee posteriorly
positive if the hip dislocates

Ortolani- testing for reduction of dislocated hip:
flex hip to 90
gently abduct the hip and exert and upward force
positive if clunk is heard as the hip relocates