Neonatology Flashcards
1
Q
What is the definition of pre-term?
A
<37 weeks
2
Q
What is the defintion of extremely pre-term?
A
<28 weeks
3
Q
What is the defintion of low birthweight?
A
<2500g
4
Q
What is very low birthweight defined as?
A
<1500g
5
Q
What is extremely low birthweight defined as?
A
<1000g
6
Q
What is the definition of small for gestational age?
A
Birthweight below the 10th percentile for the gestational age
7
Q
What is the definition of intra-uterine growth restriction?
A
A condition in which an unborn baby is smaller than it should be because it is not growing at a normal rate inside the womb
8
Q
What factors can cause a child to be born small?
A
- Maternal - Pre-eclampsia, Poor nutrition
- Foetal - Chromosomal, Infection (CMV)
- Placental - Placental Abruption
- Other - Twin prgenancy
- Normal
9
Q
What are the prognostic outcomes of extreme prematurity?
A
- 1/3 die
- 1/3 mild disability
- 1/3 moderate to severe diability
- 1/6 entirely normal
10
Q
When does the heart begin to develop?
A
3rd week
11
Q
When does the heart begin beating?
A
4th week
12
Q
When is the critical period of heart development?
A
20 weeks
13
Q
What BP would a neonate have on day 1?
A
70/40
14
Q
What is the normal resp. rate in a newborn child?
A
40-60/min
15
Q
What is the normal heart rate for a newborn?
A
120-160 bpm
16
Q
How do new born babies generate heat?
A
Metabolic heat production - brown fat - uncoupled ATP cycle
17
Q
What are the modes of heat loss in a newborn?
A
- Convection
- Conduction
- Evaporation
- Radiation
18
Q
What is the definition of stillbirth?
A
Foetus born with no signs of life >/= 24 weeks pregnancy
19
Q
What is the definition of perinatal?
A
Pertaining to the period immediately before and after birth
20
Q
What is the defition of large for gestational age?
A
>90th centile for gestational age
21
Q
What is the definition of term pregnancy?
A
37-41 weeks
22
Q
What is the definition of post-term?
A
>/= 42 weeks pregnancy
23
Q
How soon after delivery does the first breath normally occur?
A
6 seconds
24
Q
How long does it take to establish normal breathing in a newborn?
A
30 seconds post delivery
25
When does physiological jaundice disappear in a term inffant?
7-10 days
26
How long can physiological jaundice last in pre-term infants?
Up to 21 days
27
What percentage of term babies can develop jaundice?
60%
28
What percentage of pre-term babies can develop jaundice?
80%
29
How much weight can children lose in the first few days of life?
up to 10%
30
When do children pass urine for the first time?
Within 24 hours
31
At what age do children pass meconium?
24-48 hours
32
Why do children experience diureses in the first few days of life?
* **Slower GFR**
* **Reduced Na absorption**
* **Decreased ability to concentrate or dilute urine**
33
What are important features to look at in routine examination of a newborn?
* **Birthweight, gestational age**
* **Head circumference**
* **Fontanelles**
* **Face**
* **Plethora/pale**
* **Jaundice**
* **Eyes - red reflex**
* **Palate**
* **Breathing**
* **Heart**
* **Abdomen**
* **Femoral pulses**
* **Genitalia/anus**
* **Muscle tone**
* **Back and spine**
* **Primitive reflexes**
* **Hips**
34
Whithin what time period should a newboarn have had a routine examination?
72 hours
35
What is neonatal plethora?
Ruby red colouring - Caused by polycytaemia
36
What would a tense fontanelle potentiallu indicate?
* **Raised ICP**
* **Late meningitis**
37
What is the following and how significant is it?
**Milia** - white pimples on the nose and cheeks, from retention of keratin and sebaceous material in the pilosebaceous follicles
***_Resolves spontaneously_***
38
What is the following?
How significant is it?
**Miliaria** - Obstruction of immature sweat glands
**Relatively insignificant**
39
What is the following and how significant is it?
**Erythema toxicum** - common rash that appears at 2-3 days of age, consisting of white pinpoint papules at the centre of eryhtematous base. The lesions are concentrated on the trunk
***_Resolves spontaneously_***
40
What is the following and how significant is it?
**Sebaceous naevus** - hamartomatous lesion
**Risk of malignancy later in life**
41
What is the following and how significant is it?
**Strawberry naevus** (cavernous haemangioma) - appears in first month of life. Increases in size from 3-15 months, then regresses. Some lesions can interefere with eyesight/airway depending on location - give topical/oral propranalol
***_Significant - Ulceration or haemorrhage may occur_***
42
What is the following and how significant is it?
**Mixed haemangiona** - benign vascular tumors of childhood, characterized by endothelial cell proliferation
43
What is the following and how significant is it?
**Mongolian Blue spot** - black/blue macular discolouration at the base of the spineand on the buttocks; occasionally legs and other parts of the body. Usually, but not invariably, in Afro-Carribean and asian infants. Fade slowly over first few years
***_Not significant - resolves spontaneously_***
44
What is the following and how significant is it?
**Port Wine Stains** (naevus flammeus) - mark caused by vascular malformation of the capillaries in the dermis. Present from birth and usually grows in the infant
***_Significant - associated with Sturge-Weber syndrome and Klippel-Trenauny syndrome_***
45
What is the following and how significant is it?
**Stork marks (capillary haemangioma)** - pink macules on upper eyelid, midforehead and nape of the neck arising from distention of dermal capillaries. Fade after a year
***_Not significant - spontaneously resolve_***
46
What is the following and how significant is it?
**Giant melanocytic naevus** - Large area of pigmentation. is Defined by one or more large, darkly pigmented and sometimes hairy patches. Caused by genetic mutation
*_**Significant** **- can develop into melanoma**_*
47
What is the following and how significant is it?
**Cafe-au-lait spot** - flat, pigmented birthmarks caused by a collection of pigment-producing melanocytes in the epidermis of the skin.
***_Significant - may be associated with neurofibromatosis type 1 and McCune-Albright syndrome_***
48
What could the following be?
* **Cephalohaematoma**
* **Caput succedaneum**
49
What is caput succedaneum?
Serosanguinous, subcutaneous, extraperiosteal fluid collection with poorly defined margins caused by the pressure of the presenting part of the scalp against the dilating cervix during delivery.
***_Crosses suture lines_***
50
What is cephalohaematoma?
Collection of blood between the skull bone and the periosteum. Gradually develops and is margined along the sutures
51
How would you distinguish between caput succedaneum and cephalohaematoma?
* **Caput crosses suture lives, cephalohaematoma does not**
* **Caput present from birth**
* **Caput pits, cephalo does not**
52
What are short term complications of pre-term delivery?
* (**RDS) respiratory Distress Syndrome**
* **Pneumothorax -** Ventilation management and complications
* **Biochemical disorders e.g. acidosis,**
* **Temperature control, Nutrition and fluid management,**
* **Necrotising enteric colitis (NEC)**
* **Brain haemorrhage (IVH)**
* **Circulatory issues (e.g. PDA)**
* **Jaundice**
53
What is respiratory distress syndrome?
Deficiency of surfactant due to prematurity -\> alveolar surface tension lowers -\> widespread alveolar collapse and inadequate gas exchange -\> Hypoxia -\> decreased CO, HTN, Acidosis and renal failure
The more pre-term, the higher the risk
54
When is RDS most common?
Children born \<28 weeks
55
What are the most common features to see in a child with RDS?
At delivery or within 4 hours of birth:
* **Increased respiratory effort** - intercostal/subcostal recession
* **Exhaustion**
* **Tachypnoea**
* **Expiratory grunting**
* **Cyanosis** - if severe
56
What would be your differential in newborn with tachypnoea, chest recession and grunting?
* **RDS**
* **Meconium aspiration**
* **Transient tachypnoea of the newborn** - excess fluid, resolves in 24 hours
* **Congeital pneumonia** - group B strep
* **Teacho-oesophageal fistula**
* **Congenital lung abnormality**
57
What does the following demonstrate?
**Respiratory distress syndrome**
58
How do you prevent RDS in a pre-term baby?
Antenatal steroids - dexamethasone
59
How would you manage a newborn with RDS?
***_Delay cord clamping for as long as possible_***
* **Raised ambient oxygen**
* **Monitor bloods**
* **Surfactant therapy**
* **CPAP/high-flow nasal cannula**
* **Invasive mechanical ventilation** - if = 26 weeks; extubate as soon as possible
60
If, when treating a newborn for RDS, there is and deterioration, what should you check for?
* **D**isplaced ET tube
* **O**bstruction
* **P**neumothorax
* **E**quipment failure
61
What is bronchopulmonary dysplasia?
Chronic lung disease due to damage caused by mechanical ventilation (barotrauma) and long-term use of oxygen (toxicity) - often a complication of treatment of RDS in pre-term infants
62
How does bronchopulmonary dysplasia present?
* **Hypoxia**
* **Difficulty weaning from ventilator**
63
What tests can be done to investigate for BPD?
* **CXR** - hyperinflation, rounded radiolucent areas
* **Histology** - necrotising bronchiolitis with alveolar fibrosis
64
how would you manage a child with BPD?
* **Patience**
* **Nutrition and growth**
* **Steroids**
65
How would you treat a newborn who was experiencing episodes of apnoea/desaturation?
* **Can treat with caffeine**
* **CPAP**
66
What is meconium aspiration?
Aspiration of meconium when in-utero. 8-20% of babies pass meconium before birth. Increases in prevalence with increasing gestational age.
Results in mechanical obstruction and chemical irritation
67
What is MSAF?
Meconium-stained amniotic fluid
68
What can cause passing of meconium in the uterus?
* **Foetal maturity**
* **Foetal distress**
69
What problems can aspiration of meconium cause?
* **Obstruction**
* **Surfactant dysfunction**
* **Pulmonary vasoconstriction**
* **Infection**
* **Chemical pneumonitis**
70
What is this?
**Meconium -** first stool passed composed of materials ingested during the time the infant spends in the uterus: intestinal epithelial cells, lanugo, mucus, amniotic fluid, bile, and water.
71
What is this and how significantis it?
**Subconjunctival haemorrhages**
***_Not signficant - reflect strain of birth - may need to distinguish from NAI_***
72
What is this and how significant is it?
**Acrocyanosis/Peripheral cyanosis of hands and feet** - due to immaturity of peripheral vasculature
***_Not significant - normal within 1st day of life_***
73
What is an intraventricular haemorrhage?
Bleeding into the fluid-filled areas (ventricles) inside the brain. The condition occurs most often in babies that are born early (25% of those under 1500g).
Premature infants lack mature vasculature in the subependymal germinal matrix. This, coupled with trauma of birth or RD, can cause haemorrhage.
74
What are signs of IVH?
* **Seizures**
* **Bulging fontanelles**
* **Cerebral irritability**
75
If you suspected IVH, how would you investigate?
* **MRI**
76
What complications are associated with IVH?
* **Decreased IQ**
* **Cerebral palsy**
* **Hydrocephalus**
77
How could you prevent IVH?
Antenatal steroids
78
How would you manage IVH in a neonate?
Symptomatic treatment
79
What is periventricular leukomalacia?
Form of white-matter brain injury, characterized by the necrosis (more often coagulation) of white matter near the lateral ventricles.
Can occur due to haemorrhage, ischaemia or inflammation
80
What can periventricular leukomalacia cause?
* **Spastic diplegia**
* **Cognitive impairment**
81
What can occur as a result of IVH?
* **PVL -** Periventricular leukomalacia
* **PHH** - Post-haemorrhagic hydrocephalus
82
What is patent ductus arteriosus?
The ductus arteriosus remains open, especially in pre-term infants -\> causes left to right shunt. Introduces additional blood to pulmonary circulation -\> over perfusion of the lungs -\> lung oedema
83
How would PDA present clinically?
Can be asymptomatic
* **Apnoea**
* **Bradycardia**
* **Collapsing pulse**
* **Thrill,** **Machine murmur, Loud S2** - Below left clavicle
* **Faltering growth**
* **Signs of heart failure**
84
How would you manage PDA?
Investigate (ECHO) to ensure no duct dependent circulation present, then:
* **Prostaglandin synthase inhibitor**- pharmacological closure
* **Ibuprofen**
* **Indomethacin**
* **Endovascular surgery** - 1 year if ibuprofen does not work
85
How would you prevent convective heat loss in a newborn?
* **Raise ambient temp**
* **Clothe, including head**
* **Avoid draughts**
86
How would you prevent heat loss by radiation in a neonate?
* **Cover baby**
* **Double walls for incubators**
87
How would you prevent evaporative heat loss in a neonate?
* **Dry wrap at birth**
* If extreme preterm - directly into plastic bag at birth without drying
* **Humidify incubator**
88
How would you prevent conductive heat loss in a neonate?
Nurse on heated mattress
89
What can hypothermia in neonates cause?
* **Hypoxia**
* **Hypoglycaemia** - increaed energy consumption
* **Faltering growth**
* **Death**
90
What makes pre-term infants more prone to developing hypothermia?
* **Larger surface area to volume ratio**
* **Thin skin**
* **Little subcutaneous fat**
* **Cannot generate heat by shivering**
91
What is necrotising entero-colitis?
Inflammatory bowel necrosis
92
What are risk factors for the development of NEC?
* **\<1500g weight**
* **Enteral feeds**
* **Bacterial colonisation**
93
How can NEC present?
* **Feed intolerance**
* **Vomiting** - bilious
* **Distended abdomen**
* **Stool + fresh blood**
* **Rapid shock**
94
What complication can occur in NEC?
Perforation of the bowel
95
How would you manage a child with NEC?
Based on Bell's Criteria
* **Conservative treatment** - stop feeding
* **Abx and parenteral feeding** - length of time based on grading
* Vanc + Gent
* Metranidazole
* **Surgery** - if bowel perforated
96
What are long term complications of prematurity?
* **Retinopathy of permaturity**
* **Periventricular leukomalacia (PVL)**
* **Post haemorrhagic hydrocephalus (PHH)**
* **Chronic lung disease/ Broncho Pulmonary Dysplasia (BPD)**
* **Developmental delay**
* **Cerebral palsy**
* **Poor growth**
97
What can cause hypoglycaemia in neonates?
* **Small for gestational age**
* **Hypothermia**
* **Hyperinsulinaemia** - diabetic mother
* **Limited glucose supply**
98
How can hypoglycaemia present in neonates?
* **Irritable**
* **Jitteriness**
* **Apnoea**
* **Lethargy**
* **Drowsiness**
* **Seizures**
99
How would you initially approach investigating and managing a centrally cyanotic baby?
**Investigation**
* Examination
* Monitor Ecg
* Blood gas
* CXR/Echo
**Management**
* Oxygen therapy
* Start prostin (prostaglandin which will keep duct open) -\> refer to cardiology
100
What is retinopathy of prematurity?
Changes in developing vasculature at the junction of the vascularised and non-vascularised retina. The excessive vascular proliferation can lead to retinal detachement, fibrosis, and subsequent blindness
101
What are risk factors for ROP?
* **Low birth weight**
* **Prematurity**
* **Fluctuating supplemental oxygen** - High concentrations of supplemental oxygen causes increased vascular proliferation -\> tight control has lead to decrease in rate of ROP
102
What is the prevalence of ROP in those under 750g birthweight?
62%
103
What is the prevalence of ROP in those with a birthweight over 1000g?
10%
104
How would you screen for ROP?
Indirect opthalmoscopy/wide field retinal screening
105
What screening criteria are used to determine the need for screening of a neonate for ROP?
* **\<27 weeks** - screen at 30-31 weeks
* **27-32 weeks** - screen at day 28-35
Repeat screening 2-weekly depending on severity
106
How would you treat neonates with ROP?
* **Diode laser therapy** - reduces impairment
* **?Anti-VEFG**
107
What percentage of those with ROP develop severe bilateral visual impairment?
1% of very low birthweight (mostly \<28 weeks)
108
What is transient tachypnoea of the newborn?
Delay in the resorption of lung fluid, causing tachypnoea
109
What is the most common cause of respiratory distress in term neonates?
Transient tachypnoea of the newborn
110
How long does it take TTN to resolve?
1 day - although can be several
111
What are less common causes of respiratory distress in a neonate than transient tachypnoea of the newborn?
* **Meconium aspiration**
* **Pneumonia**
* **RDS**
* **Pneumothorax**
* **Persistent pulmonary hypertension**
* **Milk aspiration**
112
What are rare pulmonary causes of respiratory distress in a neonate?
* **Diaphragmatic hernia**
* **Tracheo-oesophageal fistula**
* **Pulmonary hypoplasia**
* **Obstruction**
* **Pulmonary haemorrhage**
113
What can cause foetus to pass meconium?
Foetal hypoxia/distress
114
What is persistent pulmonary hypertension of the newborn?
Hypertension within the pulmonary tree caused by increased pulmonary vascular resistance -\> right to left shunt in the lungs, atria and ductus arteriosus
Present as cyanotic soon after birth
115
What can cause persistent pulmonary hypertension of the newborn?
* **Meconium aspiration**
* **Asphyxia**
* **RDS**
* **Septicaemia**
116
What are non-pulmonary causes of respiratory distress in a newborn?
* **Congenital heart disease**
* **HIE**
* **Severe anaemia**
* **Metabolic acidosis**
117
What is a diaphragmatic hernia?
Occur when the diaphragm does not form completely, leaving a hole. This allows the bowel contents to herniate through and impinge on the lungs
118
What percentage of those treated for RDS develop pneumothorax?
10%
119
How does pulmonary interstitial emphysema occur in children being treated for RDS?
Air from overdistended alveoli may track into the interstitium
120
In what gestational category does apnoea most commonly occur; term or pre-term?
Pre-term
121
What is important to be aware of in preterm infants with regards to fluid balance?
Requirements with vary with gestational age, clinical condition, plasma electrolytes, urine output and weight change.
122
What is the usual fluid requirement on day one of life for most pre-term infants?
First day of life - ***_60-90 ml/kg_***. This increases by about 20-30 ml/kg/day to 150-180ml/kg/day by day 5
123
What is important to remember about nutritional requirements of a pre-term infant?
High nutritional requirement due rapid growth. pre-term infants at 28 week s double their birthweight in 6 weeks, and treble in 12 weeks
124
What age are infants mature enough to suck and swallow milk?
35-36 weeks - anything less and they may need NG tube feeding
125
How can you prevent osteopenia of the newborn?
Phosphate, calcium and vitamin D supplementation
126
If a baby is extremely pre-term and the mother cannot breastfeed, what can be done to ensure the infants nutritional requirements are met?
Donor breast milk
127
How would you feed a very immature or sick infant?
**Parenteral feeding** - PIC or umbilical venous catheter
128
What risks are associated with parenteral feeding in premi's?
* **Septicaemia**
* **NEC**
129
What is the definition of early onset sepsis?
\< 48 hours
130
How does early sepsis occur in the neonate?
Bacteria ascend the birth canala and invade the amniotic fluid. This fluid gets into the lungs - Pneumonia
Congenital virus/early onset listeria - infection acquired via the placenta following maternal infection
131
What increases the risk of early onset sepsis?
* **Prolonged/Premature rupture of membranes**
* **Maternal infection/pyrexia/chorioamnionitis/UTI**
* **Group B Streptococcus**
* **Preterm labour**
* **BReaks in neonatal skin/mucosa**
132
What are causative organisms of early onset neonatal infection?
* **Group B streptococcus**
* **Listeria monocytogenes**
133
How do septic neonates present clinically?
* **Fever/temp instability**
* **Poor feeding**
* **Vomiting**
* **Diarrhoea**
* **Apnoea**
* **Respiratory distress**
* **Abdominal distention**
* **Jaundice**
* **Shock/Collapse**
* **Irritability**
* **Seizures**
* **Lethargy/drowsiness**
134
What would potentially indicate that a neonate is suffering from meningitic sepsis?
Signs of neonatal sepsis, plus:
* **Tense/bulging fontanelle**
* **Head retraction** (opisthotonos)
135
What is the definition of late onset sepsis?
\> 48 hours after birth
136
How would you investigate/initially manage suspected neonatal sepsis?
* **ABCDE**
* **Supportive therapy** - ventilation, volume expansion, intotropes
* **Bloods** - FBC, CRP, BCs
* **CXR**
* **LP** - if suspected meningitis
137
How long does it take for CRP to rise after initial infection?
12-24 hours - therefore negative does not necessarily mean no infection - may need consecutive
138
What empirical antibiotics are given in early neonatal sepsis?
**Benzylpenicillin + gentamicin** - continue for 7 days if culture positive. If negative AND no clinical symptoms, stop after 36 -48 hrs
139
If a neonate with early sepsis is BC positive, what else needs to be done?
LP
140
If a neonate with early sepsis displays neurological signs, what needs to be done?
LP
141
What are the causes of late-onset neonatal sepsis?
Nosocomial infections
* **Staph epidermidis**
* **Staph aureus**
* **E. coli**
* **Enterococcus**
* **Pseudomonas**
* **Klebsiella**
* **Serratia**
142
What are some of the nosocomial sources of infection in late-onset sepsis?
* **CVCs**
* **Invasive procedures**
* **Tracheal tubes**
143
What are the risk factors for late-onset sepsis in a neonate?
* **Central lines/catheters**
* **Congenital malformations**
* **Severe illness**
* **Malnutrition**
* **Immunodeficiency**
144
What antibiotics would you use to empirically treat late-onset neonatal sepsis?
* **Flucloxacillin + gentamicin**
* **Vancomycin** - if pre-term - Coag -ve staph
* **Consider fungal if failed treatment**
145
What antibiotic should be used in suspected neonatal meningitis?
Cefotaxime
146
What types of sepsis (early/late) can group B streptococcus cause?
Early and late sepsis
147
How does early onset group B strep sepsis present?
* **Respiratory distress**
* **Pneumonia**
* **Septicaemia**
* **Meningitis**
148
How does late onset group B strep sepsis present?
* **Meningitis**
* **Focal infection** - osteomyelitis/septic arthritis
149
What are some of the risk factors which can increase the risk of neonatal infection in a mother colonised with GBS?
* **Preterm**
* **Prolonged rupture of membranes**
* **Maternal fever \>38**
* **Maternal chorioamnionitis**
150
What can be used to prevent GBS infection in a newborn baby?
IV antibiotics to the mother
151
What is laryngomalacia?
Soft, immature cartilage of the upper larynx collapses inward during inhalation, causing airway obstruction
Gets worse at 2-3 months and most resolve without treatment
152
How would you manage meconium aspiration?
* **Suction below cords**
* **Airway support – intubation and ventilation**
* **Fluids and antibiotics iv**
* **Surfactant**
* **NO or ECMO**
153
What can be a complication of meconium aspiration?
**Persistent pulmonary hypertension of the newborn (PPHN)**
154
At what oxygen concentration does cyanosis occur?
More than 5g/dl of deoxyhaemoglobin
155
If you were presented with a blue baby, what would your differential diangosis be?
* **TGA**
* **Tetralogy of Fallots**
* **TAPVD**
* **Hypoplastic left heart syndrome**
* **Tricuspid atresia**
* **Truncus arteriosus**
* **Pulmonary atresia**
156
How would you investigate a blue baby?
* **Examination and history**
* **Sepsis screen**
* **Blood gas and blood glucose**
* **CXR**
* **Pulse oximetry**
* **ECG**
* **Echo**
* **(hyperoxia test)**
157
How would you manage a blue baby?
* **ABC**
* **Inotropes as required**
* **Fluid resuscitation**
* **Respiratory support (care with O2)**
* **Prostin (prostaglandin E2)**
* **Nitric oxide**
* **Cardiology referral**
158
If a neonate has hypoglycaemia, how would you treat it?
* **Monitor blood glucose**
* **Start iv 10% glucose**
* **Increase fluids**
* **Consider Glucagon/****Hydrocortisone**
159
If a neonate had hypothermia, what investigation would you want to do as well as trying to warm the child in an incubator?
* **Sepsis screen and antibiotics**
* **Consider checking thyroid function**
* **Monitor blood glucose**
160
What is hypoxic-ischaemic encephalopathy?
Hypoxic-ischaemic injury caused by diminished tissue perfusion caused by perinatal asphyxia -\> Hypoxia, hypercarbia and metabolic acidosis
161
What are causes of perinatal asphyxia?
* **Placental problem**
* **Long, difficult delivery** - excessive/prolonged uterine contraction causing failure of gas exchange across placenta
* **Umbilical cord prolapse** - interruption of umbilical blood flow
* **Infection**
* **Neonatal airway problem**
* **Neonatal anaemia**
162
What are the stages of birth asphyxia?
* **1st Stage** - cell damage occurs with lack of blood flow and O2
* **2nd Stage -** reperfusion injury - toxins are released from damaged cells
163
What are the clinical manaifestations of mild HIE?
Typically resolves in 24h
* **Hypertonia**
* **Hyperreflexia**
* **Transient behavioral abnormalities** - poor feeding, irritability, or excessive crying or sleepiness (typically in an alternating pattern)
164
How does moderate HIE present clinically?
Full recovery within 1-2 weeks
* **Lethargic**
* **Abnormal movements**
* **Significant hypotonia/****Hyporeflexia**
* **Sluggish/absent primitive reflexes** - grasping, Moro, and sucking
* **Apnoea**
* **Seizures** - typically occur within 24 hours after birth
165
How would severe HIE present clinically?
* **No normal spontaenous movements/response to pain**
* **Fluctuant hyper/hypotonia**
* **Prolonged/refractory seizures**
* **Multi-organ failure**
166
How would you manage HIE?
* **Respiratory/Cardiac support**
* **Fluid restriction** - avoid cerebral oedema
* **Monitor for renal and liver failure**
* **Treat seizures** - anticonvulsants
* **Therapeutic hypothermia** – improves outcome especially in moderate group
167
What is involved in therapeutic cooling treatment for HIE?
* **Procedure** - Baby sedated and cooled to 33 degrees for 72 hours, then rewarmed slowly over 12 hours
* **Monitored with CFAM**
* **Cranial ultrasounds**
* **MRI at 7-10 days**
* **Neurodevelopmental follow up**
168
What are the commonest causative organisms implicated in neonatal sepsis?
* **Group B Streptococcus**
* **E. coli**
* **Listeria**
* **Coagulase negative Staphylococci (if lines in situ)**
* **Haemophilus influenzae**
169
How would you treat a neonate with suspected sepsis?
Admit NNU
* **Partial septic screen** - FBC, CRP, blood cultures, lactate, blood gas
* **Consider CXR, LP**
* **Abx**
* **Ist line** - IV penicillin and gentamicin
* **2nd line** - IV vancomycin and gentamicin
* Add metronidazole if surgical/abdominal concerns
* **Fluid management and treat acidosis**
* **Monitor vital signs**
* **Support respiratory and cardiovascular systems**
170
What is the complication of moderate to severe HIE?
Cerebral palsy
171
How would you investigate meconium aspiration?
* **Blood gas**
* **Septic screen**
* **CXR**
172
What is tracheomalacia?
Tracheal support cartilage is soft such that the trachea partly collapses especially during increased airflow
Most commonly affects distal 3rd of trachea
Most improve by 2 years of age
173
How does tracheomalacia present?
**Stridor**
Worst when crying, coughing, feeding
174
What is bronchomalacia?
Weak cartilage in the walls of the bronchial tubes, often occurring in children under six months
More likely to need CPAP +/- tracheostomy
175
How does bronchomalacia present?
* **Stridor**
* **Wheeze**
* **Dyspnoea**
176
What would you want to exclude first if a neonate had a seizure?
Meningitis
Hypoglycaemia
177
What can cause neonatal seizures?
* **HIE**
* **Cerebral infarction**
* **Septicaemia/meningitis**
* **Metabolic** - hypoglycaemia, hypo/hypernatraemia, hypocalcaemia, hypomagnesaemia, pyroxidine deficiency
* **Intracranial haemorrhage**
* **Cerebral malformation**
* **Drug withdrawal**
* **Congenital infection**
* **Kernicterus**
178
What are the most common nerve palsies seen in neonates?
* **Erb's palsy**
* **Klumpke's palsy**
179
What is a cleft lip?
Failure of fusion of the frontonasal and maxillary processes, usually around 5 weeks gestation
Can be ***_incomplete_*** (small gap in lip) or ***_complete_*** (continue into the nose)
Can be ***_unilateral_*** (left sided unilateral is most common) or ***_bilateral_*** (85% have palatal involvement)
180
What is a cleft palate?
Failure of fusion of the palatine processes and the nasal septum - by 9 weeks gestation (can occur after lip closure)
Can be ***_complete_*** (soft and hard palate involved, gap in jaw) or ***_incomplete_*** (‘hole’ in the roof of the mouth, soft palate involved)
181
What is the incidence of cleft lip/palate?
1/700 live births
182
How is cleft lip repaired?
Surgery - 3 months
183
How is cleft palate repaired?
Sirgery - 6-12 months
184
What issues are associated with cleft lip/palate?
* **Feeding issues**
* **Airway problems**
* **Associated anomalies** - trisomies
185
What is pierre robin sequence?
An association of micrognathia. posterior displacement of the tongue (glossoptosis) and a midline cleft of the soft palate
Can cause airway obstruction when the tongue falls back
186
How would you manage a child with pierre robin sequence?
**Place prone to move the tongue forward**
**For respiratory distress**
* Insert 2.5mm ET tube nasally with tip visible at back of throat
* Humidified O2 or place on CPAP
* May need endotracheal intubation
187
What is the following, and why does it happen?
***_Asymmetric crying face_***
Congenital deficiency or absence of the depressor anguli oris muscle which controls the downward motion of the lip
May be associated with cardiovascular, musculoskeletal, genitourinary, respiratory defects or 22q11 deletion
188
What is the following, and why does it happen?
***_Facial nerve palsy_***
## Footnote
Injury can result from direct trauma from forceps or from compression of the nerve against the sacral promontory while the head is in the birth canal
Decreased facial movement and forehead wrinkling on the side of the palsy, eyelid elevation, and flattening of the nasolabial folds and corner of the mouth
Crying accentuates the findings, with the most obvious sign being asymmetrical movement of the mouth. The side that appears to droop when crying is the normal side
189
How would you investigate suspected NEC?
## Footnote
**AXR**
190
What might you find on AXR in a neonate with NEC?
* **Abnormal gas pattern**
* **Dilated loops**
* **Pneumoperitoneum**
* **Pneumatosis intestinalis**
* **Thickened bowel walls**
191
What is stage I NEC based on the Bell's criteria?
Suspected disease
192
What is stage II NEC based on Bell's criteria?
Definite disease
* **IIA - mild**
* **IIB - moderate**
193
What is stage III NEC based on bell's criteria?
Advanced disease with likelihood of progressing to surgical intervention
