Neonatology (2s + 3s) Flashcards
The most common cause of hypoglycaemia in children is related to insulin treatment in type 1 DM.
Define hypoglycaemia in the neonate
- < 2.6 mmol/L in neonates
- symptoms often develop below 4 mmol/L
- < 2.8 mmol/L suggested in older children
Sepsis is the one of the most important life threatening illnesses associated w/ hypoglycaemia. What are other causes?
- endocrine → adrenal insufficiency, hypopituitarism, congenital hyperinsulinism
- metabolic → glycogen storage disease
- poisoning/dosing error → salicylates, insulin
- systemic disease → sepsis, polycythaemia, liver disease
Hypoglycaemia in neonates generally has a different mechanism to older children and is usually related to hyperinsulinaemia caused by: primary hyperinsulinism, IUGR, maternal GD and hypoxic ischaemic encephalopathy
What is the presentation of neonatal hypoglycaemia?
- commonly asymptomatic
- jitteriness
- apnoea
- poor feeding
- drowsiness
- seizures
- hypotonia
- macrosomia (if hyperinsulinism)
What is the treatment for symptomatic or severe hypoglycaemia (glucose <1.mmol/L)?
- IV bolus 3-5 mL/kg of glucose 10%
- follow w/ 10% glucose infusion IV (4-6mg/kg/min)
What is the treatment for asymptomatic hypoglycaemic infants (glucose <2mmol/L or 2-2.6mmol/L on 2 occasions)?
-
enterally fed infants
- inspect feed chart (freq/volume)
- if reluctant to feed → consider NGT
- if not tolerating milk → consider IV
- montior w/ pre-feed blood glucose levels
-
infants on IV fluids
- check IV line is working
- if glucose < 1.0mmol/L → give bolus then increase infusion rate/concentration
What is birth asphyxia?
- lack of oxygen and blood flow to brain
- happens when baby’s brain and other organs do not get enough oxygen and nutrients before, during or right after birth
- this can happen without anyone knowing
- without oxygen and nutrients, cells cannot work properly
- waste products (acids) build up in the cells + cause damage
- amount of harm depends upon time without oxygen, how low oxygen is and how quickly treatment is given
What is a stillbirth?
- a baby born with no signs of life at or after 24 weeks gestation
- almost half of stillbirths happen when the woman is in labour
- in england happens around 1 in every 200 births
What are the causes of birth asphyxia?
- placental abruption
- cord prolapse causing complete occlusion of umbilical flow
- preterm delivery
- birth trauma
- maternal analgesia
- retained lung fluid
- congenital malformations which interfere w/ breathing
What is the use of obstetric monitoring to prevent birth asphyxia?
- a normal foetal CTG is a good indicator of absence of asphyxia
- however, an abnormal one cannot provide good assessment of severity of asphyxia unless it’s profound
- foetal blood sampling or cord blood analysis can detect metabolic acidosis
What are symptoms of birth asphyxia at birth?
- not breathing or very weak breathing
- skin color that is bluish, grey or lighter than normal
- low HR
- poor muscle tone
- weak reflexes
- too much acid in blood (acidosis)
- amniotic fluid stained w/ meconium (first stool)
- seizures
How do you diagnose birth asphyxia?
- APGAR score (0-10)
- a very low apgar score (0-3) lasting longer than 5 mins may be a sign of birth asphyxia
What is hypoxic-ischaemic encephalopathy?
It’s the term used to describe presence of clinical manifestations of brain injury within 48hrs after birth asphyxia
- mild → irritable, hyper-responsive, hyperventilation, impaired feeding, staring
- moderate → lethargy, reduced spontaenous movement, seizures
- severe → no spontaneous movements or responsive to pain, tone in limbs may fluctuate between hypotonia + hypertonia, prolonged seizures
Neonatal resuscitation (BLS) is vital for birth asphyxia. What needs to be done in regarding preparation/checking equipment?
- turn on radiator, manual up to full - heat comes from top → heat is really important
- check suction
- check oxygen mask by blocking both ends, pressure should be 30 + then when releasing should be 5
- oxygen can be toxic so start off w/ air, only move up to 30% oxygen if especially pre-term or w/ senior guidance
Describe the immediate management for neonatal resuscitation?
- start clock as soon as baby placed on resuscitator
- dry baby w/ blanket first, rubbing chest + back to sitmulate baby + put on hat
- hopefully this makes baby cry, if not assess baby for 4 things:
- COLOUR, TONE, BREATHING + HR
- if baby blue w/ no chest wall movement → start 5 inflation breaths, form a C-shape seal w/ mask and then w/ other hand place one finger over mask + count (1, 2 and 3) on 3 release finger from mask, repeat this 5 times
- if there is chest wall movement but baby still blue + HR low → start ventilation breaths, similar to inflation breaths but just count 1-30, w/ finger on + off
- if there is no chest wall movement → repeat 5 inflation breaths w/ a 2 person technique
Congenital talipes equinovarus, better known as clubfoot, is a relatively common birth defect (1 in 1000 live births). It’s twice as common in males than females and around 50% of cases are bilateral.
What are the features of clubfoot?
Features can be remembered using acronym CAVE
- Cavus
- Adduction
- Varus
- Equinus
What is the management of talipes equinovarus (refers to inversion of feet)?
- cannot be manually corrected w/ dorsiflexion
- requires referral to physiotherapy
- the ponesti method consists of manipulation + progressive casting which starts soon after birth
- deformity is usually corrected at 6-10wks
- an achilles tenotomy required in ~85% cases (under LA)
- night time braces should be applied until child is 4 yrs
- relapse reate is ~15%
What is the management for positional talipes?
- brought into normal position w/ very little pressure
- may not need any treatment beyond just gentle straightening exercises
- can be done by parents w/ each nappy change
What are the common congenital infections and their features?
A majority of underlying chronic disorders in children are either clearly genetic or have a genetic susceptibility. Dysmorphic features include physical features, particularly unusual facial features that are not normally found in a child of the same age or ethnic background.
What are the features of DiGeorge syndrome?
- deletion on chromosome 22
- leading to defective development of pharyngeal pouch system
- classic triad of:
- cardiac abnormalities (TOF, VSD, interrupted aortic arch)
- hypocalcaemia (2o to parathyroid hypoplasia)
- absent/hypoplastic thymus
- other features frequently seen include developmental delay, speech and feeding problems as well as palatal abnormalities (70%)
Williams Syndrome is a developmental disorder affecting many parts of the body. It’s characterised by mild-moderate intellectual disability or learning problems, unique personality characteristics, distinctive facial features + CVS problems.
What are characteristics of individuals affected by Williams syndrome?
- struggle w/ visual-spatial tasks → drawing + assembling puzzles
- tend to do well on tasks that involve spoken language, music + learning by repetition (rote memorisation)
- outgoing, engaging personalities + tend to take extreme interest in others
- ADD, anxiety + phobias common
- distinctive facial features: broad forehead, short nose, full cheeks, wide mouth w/ full lips
-
congenital heart disease in 80%
- 75% supravalvular aortic stenosis
- 25% supravalvular pulmonary stenosis
Angelman syndrome is a complex genetic disorder that primarily affects the nervous system.
What are characteristic features of this condition?
- delayed development → noticeable by 6-12months
- intellectual disability
- severe speech impairment
- ataxia
- epilepsy + microcephaly
- happy, excitable demeanor, freq smiling/laughter + hand-flapping
- hyperactivity, short attention span + fascination w/ water are common
- have difficulty sleeping + need less sleep than usual
Russel-Silver syndrome is a growth disorder characterised by slow growth before and after birth. Babies w/ this condition have failure to thrive.
What are key features of Russel-Silver syndrome?
- thin w/ poor appetites
- hypoglycaemia due to feeding difficulties
- adults are short, avg height for men = 4’11, women = 4’7
- small, triangular face
- prominent forehead
- narrow chin + small jaw
- downturned corners of mouth
- clinodactyly
Beckwith-Wiedemann syndrome is a condition that affects many parts of the body. It’s classified as an overgrowth syndrome - affected infants are considerably larger than normal (macrosomia) + tend to be taller than their peers during childhood. Growth begins to slow by age 8 and as adults they are not unusually tall.
What are the signs + symptoms?
- omphalocele → opening in wall of abdo showing abdo organs
- umbilican hernias common
- macroglossia → may interfere w/ breathing, swallow + speaking
- other major features of this condition incl abnormally large abdo organs (visceromegaly), creases or pits in skin near ears, hypoglycaemia in infancy + kidney abnormalities
- inc risk of developing tumours, esp Wilms tumour
