Neonatology Flashcards
What are some RFs for neonatal infections (4)
Preterm (no IgG across placenta until 3rdT) Cervical infection Hosp derived: PROM (>18hrs) Indwelling lines/catheters
What % of women are GrpB Strep carriers?
What are the RFs for neonatal infection in a colonised mother? (5)
10-30% pregnant women
Faecal/vaginal carriage
Preterm PROM Previously infected infant Maternal pyrexia Maternal chorioamnionitis
What are some complications of neonatal GrpB Strep infection? (5)
Early onset sepsis (48hrs):
Newbon resp distress
Pneumonia
Septicaemia
Late onset (48hrs - 3m): Meningitis Focal infection (osteomyelitis, septic arthritis)
What 3 general features would make you suspect neonatal sepsis?
Resp distress
Apnoea
Temp instability
If suspect neonatal sepsis, how is this managed? (Ix (5) + Tx)
Septic screen: CXR LP Blood cultures FBC (detects neutropenia) CRP (helpful but takes 12-24hrs to rise)
Broad spec Abx
What is the regime in neonatal sepsis if cultures come back +ve / -ve ?
-ve and clinical signs return to normal → stop Abx after 48hrs
+ve → continue Abx, check for neuro signs + culture CSF
What is the regime for prophylactic intrapartum IV Abx for neonatal sepsis?
Either:
Screen at 35-38wks to identify carriers
Or:
Abx given to high-risk mums
What is the incidence of congenital CMV infection?
How is it transmitted?
4 in 1000 live births (0.4%) (commonest congenital inf)
(1% women have primary infection during preg + 40% those infants get infected)
Transmitted via saliva / genital secretions / breast milk
What is the presentation of CMV infection in mothers + in babies?
Mums (healthy): mild non-specific infection
But more significant infection in immunocompromised + foetuses
90% babies normal + norm devel
5% birth features: hepatosplenomegaly, petechiae, neurodevelopment (sensorineural loss/ CP/ LDs etc)
5% features later (e.g. sensorineural loss)
How is maternal/neonatal CMV infection managed?
Antivirals + ganciclovir (potential treatment)
What type of pathogen is toxoplasmosis?
What is the incidence of neonatal toxoplasmosis infection??
How is it transmitted normally + mum-baby?
Protozoan (food contamination + faecal-oral)
0.1 in 1000 live births
If mum in primary infection (parasitaemia) → transplacentally 40% infants get infected
What are the clinical features / presentation of neonatal toxoplasmosis infection? (4)
How is it treated in the neonate?
Retinopathy
Hydrocephalus
Cerebral calcification
Long-term neuro disabilities
1yr pyrimethamine + sulfadiazine
What are the neonatal effects of maternal rubella infection at different gestations?
<8/40 → deafness, congenital heart disease + cataracts (80%)
13-16/40 → impaired hearing
>18/40 → minimal effects
List some clinical features of HIV in an untreated child? (6)
Lymohadenopathy Parotid swelling Hepatosplenomegaly Thrombocytopenia Recurrent fever Serious recurrent infections (→ AIDS)
What are the main principles of HIV management in children / young people? (6)
Anti-retrovirals
PCP prophylaxis
Immunisations (Hep A/B, VZV, influenza)
Do NOT give BCG (live vaccine)
Regular FU in family clinic (wt, neurodevel)
Education of safe sex etc for adolescents
What measures can be taken to avoid vertical transmission of HIV? (4)
What is the change in transmission risk if these measures are taken?
Get viral load as low as poss around time of delivery
Active labour management (avoid PROM / unnecessary instrumentation)
Pre-labour C-Section
Avoidance of breast feeding
Risk from 25-40% reduces to 1%
What are the effects of neonatal Hep B/C infection?
How is it treated?
Increased risk of chronic hepatitis (+ assoc probs)
Tx by passive immunisation within 24hrs
How does neonatal herpes infection present? (3)
Commoner in preterms Presents upto 4wks: Localised herpetic skin/eye lesions Encephalitis Disseminated disease (v high mortality)
How is maternal/neonatal herpes managed?
C-Section at delivery
Antivirals
List the symptoms of neonatal syphilis infection (7)
Failure to thrive
Irritability
Fever
Hepatosplenomegaly
Bone inflammation
Nose (no bridge + discharge)
Rash (mouth/anus/genitalia)
What are some complications of neonatal syphilis infection? (4)
How is it treated?
Blindness
Deafness
Face deformities
Neurological probs
Treated with penicillin
How may neonatal chlamydia infection present? (2)
How is it treated
Conjunctivitis + eyelid swelling after birth / 1-2wks old
Possibly pneumonia at 4-6wks
Tx: oral erythromycin
What are the maternal antenatal complications of gonorrhoea infection?
+ Neonatal effects?
+ Neonatal treatment
Maternal: chorioamnionitis + higher risk premature labour
Neonate: opthalmia neonatorum (purulent discharge, lid swelling + corneal haze)
Urgent penicillin / 3rd gen cephalo (prevent blindness)
How is SGA / IUGR officially determined?
SGA = <10th centile IUGR = wt + abdo circumference on lower centile than head (asymmetrical)
List some maternal RFs for IUGR? (9) (opposed to placental + fetal)
Smoking
Alc / drug abuse
Older mums
HT/Heart disease DM Renal Coeliac (untreated) Thrombophilia
Drugs (warfarin/steroids/phenytoin)
List some placental RFs for IUGR? (3)
List some fetal RFs? (4)
Pre-Eclampsia
Small placenta
Placenta cell death
Multiple pregnancy Csome abns (Downs/Turners/Edwards/Patau's) Congenital defects assoc w. SGA Intrauterine infection (Rubella, CMV, toxo, syphilis)
What further Ix are done in IUGR/SGA? (2)
Detailed USS (assess risk csome defect) Umb aa Doppler (assess placental insufficiency)
What are the 4 main clinical signs of neonatal respiratory distress?
Tachypnoea
Laboured breathing (recession/flaring/tug)
Expiratory grunting
Cyanosis (if severe)
What are the causes of neonatal respiratory distress? (7)
Tasty Roll-ups Can Damage the Heart Some May say
Transient tachypnoea of the newborn Respiratory distress syndrome Congenital pneumonia Heart disease Septicaemia Diaphragmatic hernia Meconium aspiration
What is the commonest cause of respiratory distress
in term babies?
in premature babies?
in Prolonged pregnancies?
Term = transient tachypnoea of newborn Preterm = respiratory distress syndrome Post-term = meconium aspiration
What causes transient tachypnoea of the newborn?
How is Dx made?
How is it managed?
Due to delay in resorption of lung fluid (commoner in C-Section babies)
Dx (after exclusion of other causes) - CXR shows fluid in horizontal fissures
Usually settles within a day but poss require atmospheric O2
What is respiratory distress syndrome due to in preterms? What could it be due to in term babies?
Defc in surfactant + immature respiratory centre in brain
Term babies - genetic / maternal DM / meconium aspiration
How is respiratory distress syndrome managed? (2)
Antenatal steroids 48hrs before delivery if <34wks (→ lung maturation)
Artificial surfactant
What are the RFs for congenital pneumonia? (3)
How is it managed?
PROM
Chorioamnionitis
Low birth wt
Managed with broad spec Abx (early until microscopy back)
What effects does meconium aspiration have on the lungs? (3)
What is a further complication?
Mechanical obstruction Chemical pneumonitis (destroys surfactant) Predispo to infection
Lungs overinflate + causes patches of collapse/consolidation
Can → air leak (pneumothorax + pneumomediastinum)
How is meconium aspiration managed?
What is a complication of the management?
Require artificial ventilation
May → persistent pulmonary HT of newborn (where difficult to achieve adequate oxygenation despite high pressure ventilation)
What are some common problems with prematurity? (11)
Respiratory distress Necrotising enterocolitis (NEC) Infection (no IgG until 3rdT) Hypoglycaemia Temperature control Apnoea of prematurity Retinopathy of prematurity Intraventricular haemorrhage Bronchopulmonary dysplasia Neurodevelopment complications Nutrition problems
What are some RFs for NEC
Preterm (in 1st week of life)
Cows milk fed (not breast)
What are the features of NEC (4)
What Ix can be done
Stops tolerating feeds
Abdomen distends
Stool contains fresh blood
(can progress to) shock / bowel perf
Seen on AXR
How is NEC managed? (4)
Stop oral feeds + parenteral
Broad spec Abx
Artificial ventilation often required
Surgery for perforations
What are some features of neonatal hypoglycaemia?
Apnoea
Seizures
Jitteriness
Irritability
Lethargy
Drowsiness
How is neonatal hypoglycaemia prevented / managed?
Early/frequent feeding with breast milk
Regular monitoring if at risk
IV infusion if 2 levels <2.6 or one <1.6 (high concs given to avoid peripheral skin necrosis)
Why are preterm infants particularly vulnerable to hypothermia?
Large SA:V Thin skin / heat permeable Little subcut fat Nursed naked Cannot curl up / shiver Higher neutral temp range of minimal energy consumption
What happens in apnoea of prematurity? 3 features
What gestational age babies does it occur in?
Episodes of apnoea, bradycardia + desaturation
Common in very low birth wt babies <32wks gestational age
What is the main cause of apnoea of prematurity?
List some other underlying causes for apnoea of prematurity? (8)
Mostly due to central resp control
Infection Anaemia Electrolyte disturbance Hypoglycaemia Hypoxia Seizures Heart failure Aspiration
How are the apnoeic episodes in apnoea of prematurity managed?
Usually restarts after gentle physical stimulation
Caffeine
Potentially CPAP
How does retinopathy of prematurity occur?
What is the main RF?
What is the incidence?
Vascular proliferation at developing vessel junction of vasc/non-vasc → retinal detachment / fibrosis / blindness
RF: uncontrolled use of high conc O2
35% very low birth wt + 1% → severe bilateral visual impairment
How is retinopathy of prematurity treated?
Laser therapy
Weekly FU with ophthalmologist
What is the incidence of IVH in pre terms?
How does it present? (6)
60-70% extremely low birth wt (500-750g)
Apnoea Poor muscle tone Poss bulging fontanelle (raised ICP) Lethargy Sleepiness May progress to coma
How is IVH managed? (3)
SUPPORTIVE Correct acidosis / anaemia / hypotension Fluids Meds to reduce ICP Ventriculoperitoneal shunt
Give the definition of bronchopulmonary dysplasia
How does it occur (3)
What are the CXR characteristics? (2)
= infants with O2 requirement at post-conception age 36wks
Trauma (Lung damage from pressure/volume)
Toxicity - oxygen toxicity
Infection
CXR: widespread opacification + poss cystic changes
What are the main complications of artificial ventilation in neonates? (2)
Bronchopulmonary dysplasia (from long-term) Pneumothorax (10%)
How is ventilation weaning done in bronchopulmonary dysplasia?
CPAP → additional ambient O2
Use corticosteroids in early weaning
How can pneumothorax occur as a complication of RDS/ventilation
Air from over-distended alveoli tracks into interstitum → pulmonary interstitial emphysema → air leaks into pleural cavity
What is seen O/E in pneumothorax in neonates? (3)
O2 requirements increase
Reduced breath sounds
Reduced chest movement
How is pneumothorax prevented/managed in ventilated babies?
Given at lowest pressure to achieve good oxygenation
CXR
Chest drain
What is the growth rate in preterm babies vs term?
Preterm: double wt in 6wks + triple in 12wks
Term: double wt in 4.5m + triple in 1yr
Therefore v high nutritional requirement
How is nutrition administered depending on maturity/gestational age in pre terms?
35-36wks → suck/swallow
Less → NG
V premature → enteral
V immature / sick → parenteral via central vv catheter
How is lung fluid resorbed during the respiratory changes at birth?
How exactly does pulmonary resistance decrease so much after birth?
Chest compression during birth squeezes out 1/3rd
Adrenaline promotes resorption of rest
O2’s vasodilatory effect + alveolar expansion reduces capillary pressure in lungs
How is surfactant released during the respiratory changes at birth?
Triggered by adrenaline + steroids (+ synth)
What are the normal timeframes after birth for:
Bowels opening
Passing urine
Wt loss
BO - before birth / within 6yrs / before 24hrs
PU - up to 24hrs
Wt - lose 10% but regain in 2wks
What are some RFs for haemorrhagic disease of the newborn (3)
Occurs with Vit K defc so:
Wholly breast fed (little VitK)
Maternal anticonvulsants (impair clotting factor synth)
Infant liver disease
What are some clinical signs of haemorrhagic disease of newborn? (4) + a complication
How long can it take to present?
Mild: Bruising Haematemesis Malaena Prolonged umbilical stump bleeding Severe may → Intracranial haemorrhage
Early (1st wk) or late (1-8wks)
How is haemorrhagic disease of the newborn prevented? (2)
IM Vit K at birth
Mums on anticonvulsants need prophylaxis from 36wks+
What is screened for in a Guthrie test? (5)
When is it done
CF Hypothyroidism Haemoglobinopathies (sickle + thalass) Phenylketonuria MCAD (mitochondrial)
Done on day 5-9 (when estab feeding)
What does a newborn baby check consist of?
Birth wt / gestation / centile Posture / movement Head circumference Fontanelle Face - any syndromes Pale / excess blood (check haematocrit) Jaundice - any within 24hrs req Ix Eyes - red reflex Palate - cleft (visually + physically) Breathing + chest wall movement Heart auscultation Palpate abdo Femoral pulses (reduced in CoarcAo + raised in PDA) Genital/anus - check latency Scrotum - check presence Muscle tone Back + spine (bifida) Hips - DHH
What are some methods of hearing tests in the newborn? (2)
How done in 7-9m
10m-3yrs
4yrs+
Evoked otoacoustic emission
OR
Automated auditory brainstem response + EEG analysis
7-9m: Distraction testing
10m-3yrs: Visual reinforced audiometry
4yrs+: Audiometry
Why is a newborns acuity so poor (2)? + what is the usual acuity in a newborn
Fovea immature
Optic nn unmyelinated
(but peripheral retina well developed)
(any obstrn eg cataract will interfere with pathway devel)
Normal 6/200 in newborn
List some common newborn problems (8)
EM Can Poo / Fart Sloppy Big Shits
Mongolian blue spot
Erythema toxicum
Capillary haemangiomas
Physiological jaundice Feeding problems SGA Birth trauma Sticky eye
When does erythema toxicum (neonatorum) usually appear?
How would you describe this rash? (3)
2-3d after birth
White papules (eosinophils)
Erythematous base
Lesions mainly on trunk
How would you describe a Mongolian blue spot?
What is a RF
How is it treated?
Blue/black discolouration
At base of spine/buttocks (/legs)
Occurs in Afro-Caribbean / Asian
Fades after few yrs
How would you describe a capillary haemangioma?
Where on the body do they occur?
Pink macules
Upper eyelid / mid-forehead / neck
List some possible reasons for feeding difficulties? (4)
Cleft palate/lip
Gastro-oesophageal reflux
Premature + unable to suck/swallow
Poor technique / nipple attachment
What types (2) of birth trauma injuries can occur? + How
Cephalohaematoma = haematoma from bleeding below periosteum
Brachial plexus injury = from traction of brachial nerve roots
What are the RFs for brachial plexus injury ? (2)
What kind of palsy can it result in?
Shoulder dystocia
Breech
→ Erb palsy (C5+6): usually recover
What is sticky eye and why does it occur in newborns?
Yellow discharge + crust formation occurring in 1st 48hrs after birth
Due to blockage of tear ducts
What types of antibody involved in ABO incompatibility?
Most ABOs are IgM + don’t cross placenta
Some GrpO have IgG anti-A-haemolysin in blood → crosses placenta + haemolyses RBCs of GrpA baby
What are the clinical features of ABO incompatibility?
Haemolysis → Severe jaundice (less severe than Rh disease) which peaks at 12-72hrs
No hepatosplenomegaly
How is ABO incompatibility managed? (Dx / before birth / after)
Dx: +ve sAb on RBCs in bloods + high bilirubin
Before birth: intrauterine transfusion / early IoL at term / maternal plasma exchange
After birth: Phototherapy for jaundice / transfuse with RBCs + HCO3- to correct acidosis
What are the main RFs for congenital abnormalities? (4)
Maternal/paternal age
Infections (TORCH - toxo, other, rubella, cmv, hsv)
Toxins (alc, smok, medications)
Dietary defc e.g. folic acid
What is the prevalence of CHARGE syndrome
What are the different abnormalities?
1 in 10,000
Leading cause of congenital deafblindness
Coloboma of eye (hole in 1 eye structure) Heart defects Atresia of nasal choanae Retarded growth/devel Genito-urinary abns Ear abns + deafness
What is the incidence of VACTERL syndrome?
What are the different abnormalities?
16 in 100,000 live births
Vertebral (hypoplastic + scoliosis) Ano(-rectal) atresia Cardiac Tracheo-oesophageal fistula Esophageal atresia Renal anomalies Limb defects (extra/fused digits etc)
What is Patau syndrome due to?
What is the incidence
Trisomy 13
1 in 20,000
What is Edwards syndrome due to?
What is the incidence?
Trisomy 18
1 in 6000 (2nd commonest trisomy after Downs)
What are the features of Patau syndrome (9)
Those who survive (few): Low birth wt IUGR Congenital heart defects (ASD, VSD, PDA, dextro) Neural tube /Brain structural Cleft / scalp defects Small eyes GI malformations Urogenital malformations Polydactyly
What are the antenatal features of Edwards syndrome? (5)
Poly/oligo hydramnios IUGR Small placenta 1 umb aa Fetal distress
What are the postnatal features of Edward syndrome? (8)
Low birth wt Craniofacial abns - sim to Patau Skeleton abns - sim to Patau GI - T-O fistula / pyloric stenosis / imperf anus / inguinal Cardiac Urogenital - hydronephrosis, cystic, cryptochordism Neuro - hydrocephaly / severe LDs Pulmonary - hypoplasia
What are the diff types of neural tube defects? (5) + what are they
Anencephaly
Spina bifida occulta (failed vertebral arch fusion)
Encephalocele - brain/meninges extrusion thru midline skull
Meningocele - skin/meninges form out-pouch (cord stays within so fewer probs)
Myelomeningocele - communication b/wn neural tissue / meninges / surface (a neural plaque)
What are some associated complications with myelomeningocele? (6)
Paralysis
Sensory loss
Muscle imbalance
Hydrocephalus
Neuropathic bladder/bowel
Scoliosis
What features of ambiguous genitalia may be seen in (apparently) males? (3)
+ in (apparently) females? (3)
Male: Severe hypospadia Bifid scrotum Undescended testis/es Bilateral non-palpable testes
Female:
Clitoral hypertrophy
Non-palpable gonads
Vulva w. single opening
List some gonad/endocrine causes of sexual differentiation disorder (4)
*Excess androgens (congenital adrenal hyperplasia)
Gonadotrophin insufficiency (e.g. prader-willi)
Inadequate androgen actions
Ovotesticular disorder of sex development (DSD) (XX + Y cells in fetus)
What is the aetiology of congenital adrenal hyperplasia?
What is the incidence?
What group of people is it common in?
Many autosomal recessive disorders of adrenal steroid synthesis
1 in 5000 births
Common in consanguineous offsprings
How does congenital adrenal hyperplasia present? (3)
Ambiguous genitalia
Salt losing crises
Poss other androgenic features (boys tall / hirsutism)
What is Potters syndrome?
What causes it? (4)
Oligohydramnios → pressure in utero effects
Bilateral renal agenesis (usually)
Renal hypoplasia
Polycystic kidneys
Obstructive uropathy
Describe the physiology behind Hypoxic Ischaemic Encephalopathy
Perinatal asphyxia
→ compromised/no gas exchange (placental/pulm)
→ cardioresp depression
→ hypoxia + hypercapnia + metab acidosis
Compromised CO = reduced tissue perfusion → HIE
What are some of the antenatal/intrapartum causes of hypoxic ischaemic injury (6)
Interrupted umb aa blood flow (cord prolapse/shoulder dystocia)
Inadequate maternal placental perfusion (hypotension / major abruption)
IUGR (compromised fetus)
Anaemia (compromised fetus)
Failure of cardioresp adaptation at birth (failure to breathe)
What are some features of mild HIE seen within 48hrs of birth? (5)
Mild Irritable Excessive response to stimulation Staring eyes Hyperventilation Impaired feeding
What are some features of moderate HIE seen within 48hrs of birth? (3)
Marked abnormal tone / movement
Cannot feed
Poss seizures
What are some features of severe HIE seen within 48hrs of birth? (4)
No spontaneous movements / response to pain
Fluctuating hyper/hypotonia
Prolonged seizures
Multi-organ failure
How is HIE managed? (6)
Resp suppot EEG Fluid restriction Treat hypotension + seizures Monitor hypogly / elec imbalance Cool baby to 33/34 (prevent repercussion injury)
What is the prognosis like in mild/moderate/severe HIE?
Mild: v good prognosis + expect full recovery
Moderate: recovery only likely if normal neuro Ex + feeding by 2wks
Severe: 30-40% mortality or severe neurodisabilities eg CP
What are the characteristic facies in Potters syndrome? (4)
Where else may there be deformities (5)
Parrot beaked nose
Prominent epicanthal folds
Low set ears
Recessed chin
Cardiac / Neuro / MSK / Opthalmic
+ Pulm hypoplasia (from oligohydramnios)
