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Year 4 > Neonatology > Flashcards

Neonatology Flashcards

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1
Q

What are the two most common causes of neonatal jaundice?

And explain the pathophysiology behind them.

A
  1. Phsyiological jaundice: Increased haematocrit and decreased RBC lifespan, immature glucoronyl transferase enzyme system (slow conjugation of bilirubin), increased enterohepatic circulation.
  2. Breast milk jaundice: due to lack of milk production and subsequent dehydration, leading to exaggerated physiological jaundice.
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2
Q

What are the causes of neonatal jaundice by age?

A
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3
Q

Describe the pathophysiology of jaundice?

A
  • Jaundice is bilirubin that is deposited in the skin and mucous membranes.
  • Bilirubin is the end product of haem breakdown.
  • Lysis of red blood cells release haem from haemoglobin, haem is then converted to bilirubin and excreted.
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4
Q

What are the two forms of bilirubin and how do they move throughout the body?

A
  • Unconjugated bilirubin reversibly bound to albumin
  • Conjugated bilirubin readily excretable via the renal biliary systems.
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5
Q

When is jaundice pathological?

A
  • Within the first 24 hours
  • Conjugated hyperbilirubinaemia
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6
Q

Describe how you can estimate the amount of bilirubin causing neonatal jaundice?

A
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7
Q

What is the prevalence of neonatal jaundince in term and preterm infants?

A
  • 65% of term newborns develop clinical jaundice in first week
  • 80% of preterm infants
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8
Q

What investigations need to be ordered when working up a neonate for jaundice?

A
  1. FBC, film and reticulocytes
  2. Serum bilirubin levels
  3. Blood group
  4. Maternal blood group
  5. Direct coombs test
  6. Consider G6PD level
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9
Q

What factors increase the severity of physiological jaundice in neonates?

A
  1. Prematurity
  2. Sepsis
  3. Bruising
  4. Cephalohaematoma
  5. Polycythaemia
  6. Delayed passage fo neconium
  7. Breast feeding
  8. Genetics - certain ethnic groups, esp Chinese
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10
Q

What Ix need to be ordered in a neonate that has prolonged jaundice?

A
  1. Serum bilirubin level
  2. Conjugated fraction of bilirubin
  3. LFT
  4. Coags
  5. Abdo US _ gallbladder
  6. DISIDA/HIDA scan (with follow through)
  7. Hepatitis screen (TORCH)
  8. Liver biopsy (bile duct proliferation)
  9. TFT
  10. Metabolic screen (urine for reducing substances)
  11. PLUS usual tests:
    1. FBC, film, retics
    2. Blood group
    3. maternal blood group
    4. direct coombs test
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11
Q

What are the complications of neonatal jaundice?

A

Kernicterus: bilirubin encephalopathy

  • Is a neurological syndrome resulting from neurotoxic effects of unconjugated bilirubin on basal ganglia and brainstem nuclei.
  • Unconjugated bilirubin is lipophilic and can cross the blood-brain barrier
  • Signs and symptoms of kernicterus (first 24 hours)
    • Phase 1: Poor sucking, hypotonia and lethargy
    • Phase 2: Hypertonia and opisthotonos (severe tetanus)
    • Phase 3: Less hypertonia, high pitched cry, hearing and visual loss, poor feeding and athetosis (involuntary writhing movements)
    • Long term: Choreoathetoid cerebral palsy, Sensorineural hearing loss, upward gaze palsy, intellectual delay.
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12
Q

What is the treatment for neonatal jaundice?

A

Depends on the cause and the level and type of bilirubin:

  • Unconjugated:
    • Ensure adequate fluid intake
    • Phototherapy
    • IV immunoglobulin
    • Exchange transfusion
  • Conjugated:
    • Ensure adequate nutrition
    • Treat underlying problem
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13
Q

HOw does phototherapy work?

A
  • Phototherapy converts unconjugated bilirubin into an isomer that is soluble and can be excreted by the liver without conjugation.
  • Many wavelengths from 420-600nm of light do this (blue, green and white)
  • IT IS NOT UV light
  • Blue light is the most effective
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14
Q

What are the factors that determine efficacy of phototherapy?

A
  • Wavelength (type of light source)
  • Distance to baby: maximise irradiance by minimising patient to light source distance.
  • Skin area exposed: Maximise for intensive phototherapy with additional light source below infant
  • Irradiance: the flux of energy per unit area
  • Time: more time better
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15
Q

When do you start phototherapy?

A
  • Decision is based on:
    • Level of bilirubin
    • RAte of rise of bilirubin
    • Gestational age
    • Chronological age
    • Wellness of the baby
  • There are charts to help with this so don’t need to know the specifics
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16
Q

What are the complications of phototherapy?

A
  • Retinal degeneration
  • Temperature instability
  • Fluid balance - dehydration
  • ↑ insensible and intestinal water losses
  • Loose frequent stools
  • Bronze-baby syndrome - retention of bile pigment photoproducts these are toxic metabolites.
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17
Q

How does exchange transfusion works for neonatal jaundice?

A
  • Doubles volume - 160 mls/kg
  • Removes 80% of RBCs
  • Removes 50% of bilirubin
  • Used:
    • Group O (Kell-negative)
    • RhD - idential with the baby
    • <5 days old
    • CMV negative (or at least WBC depleted)
    • Irradiated (to prevent GVHD)
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18
Q

What are the complications of exchange transfusion?

A
  • INfection
  • Thromboembolic events
  • Acid-base, electrolyte and glucose distrubances
  • Coagulation and platelets disturbances
  • Hypothermia
  • Transfusion reaction
  • Complcations from the line used
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19
Q

What are the signs and symptoms of respiratory distress in the neonate?

A
  • Heart rate
  • Respiratory rate
  • Saturations - in air, in oxygen
  • Colour -peripheral/central cyanosis
  • Nasal flaring
  • Grunting
  • Tracheal tug
  • Supraclavicular recessions
  • Intercostal recessions
  • Subcostal recessions
  • Abdominal wall movements
20
Q

What are the 4 most common lung diseases in the neonate?

A
  1. Transient tachypnoea of the newborn
  2. Hyaline membrane disease
  3. Congenital pneumonia
  4. Meconium aspiration syndrome
21
Q

Describe the physiology, risk factors, Ix, management and complications for transient tachypnoea of the newborn?

A

Physiology

  • Results of the delay in clearance of fetal lung liquid.

Risk factors

  • Elective caesarean section
  • Preterm infants
  • Birth asphyxia

Investigations

  • CXR - interstitial oedema and pleural effusions (usually small), normal chest radiograph by 48 hours postpartum.

Management

  • Oxygen
  • CPAP
  • Rarely ventilation

Complications: potential secondary surfactant deficiency

22
Q

Describe the physiology, risk factors, Ix, management and complications hyaline membrane disease

A

Physiology

  • surfactant deficiency
  • immature type II pneumocytes
  • The lack of surfactant increases the surface tension in alveoli causing collapse → ↓ surface area for gas exchange → hypoxia + acidosis → respiratory distress.

Risk factor

  • maternal diabetes, greater prematurity
  • Premature delivery
  • prenatal asphyxia
  • multiple gestations
  • Congenital hypothyroidism
  • TTN
  • MAS
  • congenital pneumonia

Investigations

  • CXR - typically gives diffuse ground glass lungs with low volumes and a bell-shaped thorax, bilateral and symmetrical, air bronchograms, hyperinflation.

Management

  • Oxygen
  • CPAP
  • Ventilation - surfactant treatment

Complications: PIE, pneumothorax, BPD

23
Q

What are the preventative options for hyaline membrane disease?

A

Neonatal corticosteroids if risk of preterm delivery <34 weeks

24
Q

What is pathoology, risk factors, Ix and management of meconium aspiration syndrome?

A

Pathology/aetiology

  • Occurs secondary to intrapartum or intrauterine aspiration of meconium, usually in the setting of fetal distress, and usually in term or post-term infants.
  • Aspirated meconium can cause small airways obstruction and a chemical pneumonitis.

Risk factors

  • Post-term infants
  • IUGR
  • Fetal distress

Investigations

  • CXR - hyperinflation, patchy atelectasis, patchy and coarse infiltrates, 10-20% have pneumothorax.

Management

  • Tracheal suction- only if considered appropriate
  • Oxygen
  • Judicious use of CPAP
  • Ventilation - surfactant
  • Sedation and muscle relaxant
25
Q

What is pathology, risk factors, Ix and management of congenital pneumonia?

A

Aetiology

  • occurs with a transplacental spread
  • aspiration of infected amniotic fluid after prolonged rupture of membranes or during delivery.

Investigations

  • High vaginal swab
  • FBC, CRP
  • Blood cultures
  • Gastric aspirate - will grow the possible bacteria, because they have swallowed amniotic fluid
  • CXR - broad and wide spectrum of abnormalities varying from a normal chest, localised or diffuse alveolar densities, interstitial lung disease and features similar to hyaline membrane disease.
  • ETT aspirate

Management

  • Oxygen
  • CPAP
  • Ventilation - surfactant
  • IV antibiotics - ampicillin/penicillin and gentamicin
26
Q

What are the 5 most common organisms causing congenital pneumonia?

A
  1. E coli
  2. GBS
  3. Klebsiella pneumonia
  4. Listeria monocytogenes
  5. H influenzae
27
Q

Describe the pathway of neonatal rescusitation?

A
28
Q

Describe the fetal circulation, and the changes that occur from intra- to extra-uterine life.

A

In the fetus:

  • Pulmonary arterioles are constricted
  • Pulmonary blodd flow is dimished
  • Blood flow is diverted through foramen ovale and across ductus ateriosus.

After delivery:

  • Lungs expand with air
  • fetal lung fluid leaves alveoli
  • Pulmonary arterioles dilate
  • Pulmonary blood flow increases
  • Blood oxygen levels rise
  • Ductus arteriosus constricts
  • Blood flows through the lungs for oxygenation
29
Q

What is normal fetal to postnatal saturation in term/preterm infants?

in utero, delivery, 5, 8, 10 mins.

A
  • In utero: 46% Sp02
  • Delivery: 63%
  • 5 mins: 85%
  • 8 mins: 90%
  • 10 mins: 95%
30
Q

What are the signs of a compromised newborn?

A
  • Cyanosis
  • Bradycardia
  • Low blood pressure
  • Depressed respiratory effort
  • Poor tone
  • Tachypnoea/Apnoea
31
Q

What is the first step in neonatal resuscitation?

A
  • Provide warmth
  • Position; clear airway (as necessary)
  • Dry, stimuatem reposition
  • Place newborn under radiant warmer
  • Dry thoroughtly
  • Remove wet towels
32
Q

What are the clinical signs of a compromised neonate?

A
  • Cyanosis
  • Bradycardia
  • Low blood pressure
  • Depressed respiratory effort
  • Poor muscle tone
  • Tachypnoea
33
Q

Describe the 4 steps of neonate rescusitation?

A
34
Q

What needs to be done if rescusitation is not being effective?

HINT: MR SOPA

A
  • Mask - adjust
  • Reposition the head to open airway
  • Suction: mouth then nose
  • Open mouth abd lift jaw forward
  • Pressure: gradually increase pressure every few breaths until visible chest rise is noted
  • Artificial airway: ETT or LMA
35
Q

What are some common causes of failure of rescusitation measure?

A
  • Extreme prematurity: increased risk for respiratory failure, insensible water losses, hypoglycaemia and intraventricular haemorrhage
  • Airway problems: choanal atresia, Pierre Robin syndrome, tracheal webbing, oesophageal atresia with or without tracheoesophageal fistula, cystic adenomatoid malformation, cystic hygromas
  • Pulmonary compression: congenital diaphragmatic hernia, pneumothorax and pneumomediastinum
  • Miscellaneous conditions: multiple gestation, hydrops foetalis, omphalocele and gastroschisis, congenital anomalies
36
Q

What is the criteria for cessation of rescusitation of a neonate?

A
  • In infants with an Apgar score of 0 after 10min of resus, if the HR remains undetectable, it may be reasonable to stop resus but the decision must be individualised
  • Consider whether the resus was considered optimal, availability of advanced neonatal care such as therapeutic hypothermia, specific circumstances before delivery (e.g. known timing of the insult) and
    wishes expressed by the family
37
Q

What is the criteria for withholding rescucitation?

A
  • Conditions associated with high mortality and poor outcome, particularly when there has been opportunity for parental agreement
  • When gestation, birth weight, or congenital anomalies are associated with almost certain early death and there is unacceptably high morbidity among the rare survivors
38
Q

What is the routine care given to all babys within the first week of life?

A
  • Vitamin K – given as prophylaxis against haemorrhagic disease of the newborn
  • Breastfeeding – mothers may need assistance and support
  • Umbilical cord care – always wash hands before handling, keep dry and exposed to air, clean with water (avoid alcohol as it delays cord separation), fold nappy below umbilicus
  • Screening – Guthrie test (day 7); screens for phenylketonuria, congenital hypothyroidism, galactosaemia, cystic fibrosis, amino acid disorders, fatty acid oxidation disorders, organic acid disorders
  • Audiology – in the ACT newborn screening performed before leaving hospital
  • Discharge – before discharge check that feeding is being established successfully, staff do not have concerns about the mother’s handling of the baby, and the baby is well and not significantly jaundiced
39
Q

Describe normal postnatal growth.

A
  • Initial period of weight loss
    • Loss of extracellular fluid
    • Term – 5-10% of birth weight; 33% of body weight is extracellular fluid; require 100-120kcal/kg/d
    • Preterm – 8-12% of birth weight; 50% of birth weight is extracellular fluid; require 120-140 kcal/kg/d
    • Regain birth weight by 10-14d
  • Nutrient accretion
    • Weight gain – 10-20 g/kg/day
    • Length gain – 1cm/wk
    • Head circumference – 0.5-1cm/wk
40
Q

Describe the differences between breast milk and cows milk formuila?

A
41
Q

What are the goals of neonatal nurtition?

A
  • Meeting nutritional needs: carbohydrates, protein, fat, vitamin and minerals, water
  • Preventing nutritional deficiencies
  • Promoting good health
  • Nutritional ‘programming’: atopy and hypersensitivities, tendency to obesity, adult hypertension and diabetes, behaviour and longevity
42
Q

Why do some mother want or need to artificially feed their baby?

A
  • Some have problems with breastfeeding e.g. mastitis
  • Some do not want to breastfeed
  • Contraindications to breast-feeding – maternal HIV, active maternal TB, inborn errors of metabolism
43
Q

What are the 10 steps to successful breastfeeding?

A
  1. Have a written breastfeeding policy that is routinely communicated to all health care staff
  2. Train all health care staff in skills necessary to implement this policy
  3. Inform all pregnant women about the benefits and management of breastfeeding
  4. Help mothers initiate breastfeeding within a half-hour of birth
  5. Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants
  6. Give newborn infants no food or drink other than breast milk unless medically indicated
  7. Practice rooming-in – allow mothers and infants to remain together 24h a day
  8. Encourage breastfeeding on demand
  9. Give no artificial teats or pacifiers to breastfeeding infants
  10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the clinic
44
Q

What are the normal vital rangs for a newborn?

A
  • Heart rate – 110-160bpm
  • Respiratory rate – 30-60/min
  • Temperature – 36.5-37.4°C
  • O2 saturation – 91-95%
45
Q

What Ix need to be done a sick neonate?

A
  • Sepsis work-up – FBC and differential, CRP, blood culture, urine MC&S, CSF if indicated, CXR if indicated, consider aspirate of site of infection, tracheal aspirate if ventilated
  • Consider – maternal vaginal culture, placental tissue culture and histopathology, rapid antigen screen, blood gases, coagulation screen
46
Q

Maternal infection and congenital and neonatal defects.
What does maternal listeriosis cause?

A
  • Causes transplacental infection and premature labour in 5% of cases.
  • Neonatal infection is usually mutli-organ disease with granulomata, found on hte skin and pharynx.
47
Q

Maternal infection and congenital and neonatal defects.
What does maternal toxoplasma infection cause?

A
  • Hydrocephaly, seizure and chorioretinitis.

Year 4 (25 decks)

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