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Paediatrics > Neonatology > Flashcards

Neonatology Flashcards

1
Q

what is a neonate?

A

a baby up to 28 days of age

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2
Q

what is a term baby?

A

a baby born between 37-42 weeks gestation

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3
Q

what is a preterm baby?

A

a baby born before 36+6 weeks gestation

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4
Q

why do you give newborns vitamin K injections?

A

to prevent Vitamin K Deficiency Bleeding (VKDB)/haemorrhagic disease of the newborn (HDN) (same thing)

because they don’t have enough vit K in the blood

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5
Q

what can you do to prevent respiratory distress syndrome in preterm babies?

A

give maternal steroids pre-birth

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6
Q

what are defined as high risk deliveries?

A
  • pre-term (<36 weeks)
  • multiple births
  • crash/emergency c sections (metals distress, undiagnosed breech)
  • meconium stained liquor
  • instrumental deliveries
  • expected problems; abnormal scans etc
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7
Q

what is meconium stained liquor?

A

when meconium is passed when the baby is still in the womb, staining the amniotic fluid because there is bile salts and enzymes, if inhaled by the foetus = MAS meconium aspiration syndrome

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8
Q

what is sturge weber syndrome?

and what symptoms/signs are associated with it?

what is the pathology of this?

A

rare congenital neurological and skin disorder (neurocutaneous syndrome)

-port wine stains esp in the ophthalmic distribution, glaucoma, seizures, mental retardation

proliferation of arteries in the brain

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9
Q

in what populations might you see only a single palmar crease?

A

trisomy 21 - downs syndrome
fetal alcohol syndrome
other chromosomal abnormalities

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10
Q

when performing the red light reflex, what is the most likely diagnosis for….

Bilateral lack of RLR ?
unilateral lack of RLR ?

A

bilateral - congenital cataracts (if untreated can lead to a lazy eye)
unilateral - retinoblastoma

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11
Q

name the two tests performed when examining for hip dysplasia in a newborn and what they are doing?

A

Barlaw - pushing the hip joint downwards to try and displace it

Ortolani - pushing in and upwards to try and relocate it

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12
Q

what is talipes equinovarus and explain the two types and their prognosis

A

‘club foot’

positional - occurs due to positioning in the uterus, generally correctable with passive dorsiflexion of the foot

congenital - can be idiopathic or due to genetic syndromes, teratological anomalies, neuro disorders or myopathies, generally harder to treat

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13
Q

what are risk factors for infection in a term baby?

A
  • PROM (prolonged rupture of membranes)
  • mum GBS (group B strep) carrier
  • not receiving maternal antibiotics in labour
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14
Q

normal temperature range is?

A

36.5 C - 37.5 C (rough)

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15
Q

what things should you think about in an unwell term baby?

A
  • sepsis (group B strep, e.coli, listeria)
  • hypoglycaemia (ABC - DEFG - don’t ever forget glucose)
  • congenital cardiac abnormality
  • metabolic problem
  • others: transient tachypnoea of newborn, anaemia/hemolysis, birth asphyxia, seizures
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16
Q

percentage of pregnant women in the UK are group B strep carriers and what does this mean for their baby and how can you prevent this?

A

1/4 of pregnant women carry GBS

babies can get sepsis from it - septicaemia with possible pneumonia/meningitis, although most aren’t

maternal antibiotics in labour = 90% RR for early (within 1st week) GBS sepsis

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17
Q

how do you manage GBS sepsis in a unwell term baby?

what antibiotics are used?

A

ABC - DEFG

airway
breathing - oxygen, CPAP, ventilation
circulation - fluids and inotropes

DEFG - always check glucose

treat with abx - ben pen and gent until microbiology comes back

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18
Q

what do the following antibiotics cover for?

ben pen
gent
amox

A

benzyl penicillin = GBS, strep, staphs

gentamicin = gram neg and ecoli

amox = listeria

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19
Q

what does the coombs test (DAT - direct anti globulin test) look at?

A

ABO or Rhesus incompatibility

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20
Q

what do you separate the causes of neonatal jaundice in to and name some cases under each category?

A

unconjugated and conjugated

unconjugated can be further split into onset <24 hours and consent >24 hours

<24 hours - sepsis, autoimmune hemolysis (ABO incompatibility and rhesus disease), congenital infections

onset >24 hours - sepsis, homeless, congenital infections (i.e. TORCH), hypothyroidism (slow liver enzymes), metabolic disorders

OR physiological jaundice, breast milk jaundice (non pathological and diagnosis of exclusion)

conjugated bilirubin = biliary atresia, choledochal cyst, liver disease

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21
Q

how do you treat neonatal jaundice?

A

No treatment — this may be appropriate for well neonates with physiological or breastmilk jaundice and a bilirubin level below the treatment threshold. - adequate hydration through good feeding and mothers continue to breast feed

Treatment of any underlying illness (such as infection).

Phototherapy — absorption of light through the skin converts unconjugated bilirubin into products that are more easily excretable in the stool and urine.

Exchange transfusion — indicated if the baby has signs of bilirubin encephalopathy and considered if the risk of kernicterus is high or jaundice is not responding to phototherapy.

Early surgical treatment — required for conditions such as biliary atresia.

22
Q

when should you do an emergency/urgent admission in neonatal jaudice?

A

jaundice appears <24 hours of life

jaundice with features of bilirubin encephalopathy (atypical sleepiness, poor feeding, irritability)

jaundice appears > 7 days of life, appears unwell, was preterm, prolonged jaundice (2-3 weeks), pale stools/dark urine, poor feeding/concerns about weight

23
Q

what should you ask when taking a history about neonatal jaundice?

A

Obstetric history (including the mother’s Rhesus status and blood group if known) and the baby’s gestational age at birth.

Age at onset and duration of jaundice.

Feeding history (type of feeding and whether there have been any problems with adequate intake).

Number of wet or dirty nappies in a day (to assess the state of hydration).

Also specifically ask about the presence of dark urine and/or pale stools.

Signs of illness (for example lethargy, fever, vomiting, significant weight loss, irritability).

Family history of relevant conditions — for example significant haemolysis (including glucose-6-phosphate-dehydrogenase deficiency).

Ask whether any siblings or close family members have required hospital treatment such as phototherapy or exchange blood transfusion for neonatal jaundice.

Examine the neonate to assess for:
Any signs of illness, including fever.
Appropriate weight gain (compared with previous measurements if available).
Evidence of bruising (for example cephalhaematoma following ventouse delivery).

24
Q

What tests are done when a baby presents with neonatal jaundice?

A

serum bilirubin levels are usually measured in order to confirm the diagnosis and guide treatment.

Full blood count and blood film — a high or low white blood cell count or thrombocytopaenia can suggest sepsis; a haematocrit of less than 45% can suggest haemolytic anaemia; an increased reticulocyte count suggests haemolysis; a peripheral blood film may show evidence of haemolysis.

Blood group (mother and baby) — ABO incompatibility is suggested by a mother with blood group O and a baby with group A or B. Rhesus incompatibility is suggested if the mother is Rhesus negative and her baby is Rhesus positive.

DAT (direct anti globulin test - Coombs’ test) — used to diagnose ABO or Rhesus isoimmunisation.

Liver function tests — in congenital infection, liver enzymes may be increased.

Blood glucose-6-phosphate-dehydrogenase (G6PD) levels, taking into account ethnic origin — to check for G6PD deficiency.

Microbiological cultures of blood, urine, and/or cerebrospinal fluid (if infection is suspected) — to look for a source of sepsis.

25
Q

what is a TORCH screen? and what is it looking for?

A

looking for serious congenital infections:

Toxoplasmosis 
Other - parvovirus 
Rubella 
CMV 
herpes and HIV (no longer done really)
26
Q

why does physiological jaundice occur and when is it most likely to?

A

high red cell volume at birth due to increased requirements to get oxygen via placenta

decreased red cell survival - less requirement to get oxygen from the air

2-5 days after birth, should resolve around 1 week after

27
Q

why does breast milk jaundice occur and when is it most likely to occur?

A

due to:
delayed establishment of gut flora = increased bilirubin reabsorption

substances in milk inhibit conjugation and excretion of bilirubin

28
Q

what can extreme hyperbilirubinaemia lead to?

A

kernicterus - form of dystonic cerebral palsy

29
Q

what is the most likely diagnosis of a baby born preterm presenting with increased WOB, heart rate, resp rate and decreased sats and the mother had no maternal steroids?

A

respiratory distress syndrome secondary to surfactant deficiency

30
Q

what cells produce lung surfactant and when do they do this?

what does the surfactant do?

A

type 2 pneumocytes

between 24 weeks - 35 weeks (sufficient by 35 weeks)

reduces surface tension preventing alveolar collapse on expiration

31
Q

how do you treat a preterm baby with RDS?

A

respiratory support - oxygen, CPAP, ventilation

curosurf (surfactant) via endotracheal tube

and sats will improve instantly

32
Q

what is the most likely diagnosis in a preterm baby not tolerating feeds, billious aspirates and bloody stools with distended shiny abdomen with visible bowel loops?

A

necrotising enterocolitis

33
Q

what are the key complications of preterm delivery?

A

resp - respiratory distress syndrome

cardio - patent ductus arteriosus

GI - necrotising entercolitis

neuro - intraventricular haemorrhage

34
Q

what are the risk factors for preterm delivery?

A

pre-eclampsia

multiple pregnancy (twins, trips)

reduced or increased amniotic fluid (oligohydramnios or polyhydramnios)

cervical incompetence

sepsis - chorioamnionitis aka intra amniotic infection (IAI)

35
Q

what happens in necrotising enterocolitis?

A

bowel ischemia, inflammation, necrosis and even perforation

36
Q

what imaging do you do in NEC?

A

A x ray:
air in intestinal wall and free gas if perforated
- riglers sign = double wall sign, air on both sides of abdomen, free gas under diaphragm

distended bowel loops

wall thickening, fixation of the loops or reduction of intestinal air

shows a specific pattern only when there is the mucosal damage with pneumatosis of the intestinal wall and pneumoperitoneum

US scan: images in real time of the abdominal structures being able to assess the presence and validity of peristalsis of the bowel loops, detect the thickness of the intestinal wall and the presence of minimal amounts of fluid in the peritoneal cavity.

37
Q

how you do treat NEC?

A

In many cases, NEC can be treated without surgery, by resting the bowel by using intravenous feeding and treating any infection with antibiotics. During this period, your child will have a nasogastric (NG) tube passed through their nose to drain off the contents of their stomach. They will also have an intravenous infusion (drip) of fluids and medicines.

However, your child will need an operation if they develop a perforation or do not respond to the treatment above. The operation is carried out under a general anaesthetic and can last between one and four hours, depending on the severity of the NEC.

bowel rest = NBM+ NG decompression
total parenteral nutrition = TPN antibiotics = ABX

NBM, TPN, ABX

+surgery to remove necrotic tissue

38
Q

what is biliary atresia? and what can it lead to?

A

congenital abnormality = blockage or absence of bile ducts

untreated can lead to progressive liver failure

39
Q

what are clinical signs of biliary atresia?

and how do you diagnose it?

A

jaundice

pale stools

dark urine

distended abdomen due to hepatomegaly

USS and LFTs

40
Q

how do you treat and manage biliary atresia

A

treat - surgery within 2 months

extrahepatic ducts only = hepatoportoenterostomy (kasai procedure)

intrahepatic ducts = liver transplant

manage: (little evidence for some of these)

antibiotics to prevent cholangitis

ursodeoxycholic acid - encourage bile flow

ADEK - fat soluble vitamins

41
Q

when a baby is delivered whats the first thing you should do before start resus?

A

keep baby as warm as possible = dry baby, put hat, plastic bag (acts a greenhouse)

42
Q

what does ground glass appearance on CX ray in preterm infant indicate?

A

RDS

43
Q

what differentials other than surfactant deficiency should you consider to explain RDS in a newborn?

A
  • Infection/sepsis due to PROM and preterm (other risk factors: also if mum has an infection - Group B strep)
    • Congenital abnormalities of the lungs eg. lobar emphysema, cyst
    • Congenital abnormalities of the heart
    • Pulmonary hypertension of the newborn
    • Metabolic- hypoglycaemia, hypocalcaemia, hypothermia
  • pneumothorax
  • Intracranial bleed
44
Q

what antibiotics do you use to cover sepsis in newborns, including dosage, frequency and what they cover?

A

ben pen - 25 mg/kg every 12 hours (or 50, hosp dependent)
covers gram pos: staphs, streps

gent - 5mg/kg (every 36hrs)
covers gram neg

45
Q

why is a preterm baby with RDS likely to become hypogylcaemic?

A
  • Physiologic stress response to respiratory distress syndrome
  • In premature infants- they have limited glycogen stores in liver and immature liver function so an inability to generate new glucose
  • All stores used up in RDS and drop blood sugar
46
Q

what is classed as hypoglycaemic and what is the management of a preterm baby with hypoglycaemia?

A

the operational threshold for management of hypoglycaemia in a preterm neonate is defined as: plasma glucose less than 2.6mmol/L

IV bolus of dextrose and maintenance fluids and monitor

47
Q

how and when do you feed preterm babies? what with and why?

A

Preterm babies cannot suckle and also their gut is immature (can lead to necrotising enterocolitis) so can’t just feed them

Also if someone is in RSD they struggle to feed

DO NOT GIVE FORMULA if possible – would prefer donor expressed breast milk than formula if mum isn’t expressing
EBM – expressed breast milk

  • 0.5ml/hour every hour: Only after 24 hours you increase by another 0.5
  • TPN – nutrition through the vein and very slowly build up feeds
48
Q

how can you monitor the adequacy of nutrition in a newborn?

A
  • Weight gain
  • Cap blood glucose
  • Other bloods – look at U+E, calcium, phosphate, lipid profiles, liver function (production of the proteins), iron profile,
49
Q

if a preterm deteriorates suddenly and looks pale, what might you be worried about?

A 
Intracranial haemorrhage, hypoglycaemia, 
shock, 
sepsis, 
cardiovascular, 
pneumothorax
50
Q

why do we give caffeine to preterm babies?

A

Caffeine reduces the frequency of apnea, intermittent hypoxemia - stimulate resp system

51
Q

describe the possible damage sustained to preterm babies eyes, hearing, lungs and brain, and how do you monitor these?

A
  • Retinopathy of prematurity – esp if too much oxygen
    o All these babies have eye screening – ophthalmology come every 2 weeks and look in eyes for excess neurovascularisation – treated with laser therapy
  • Ears: Oto toxicity – gentamycin neurosensorial
    o Regular audiology check ups
  • Chronic lung disease of prematurity
    o Still requiring oxygen after 28 days of life – this is the definition
    o Honey comb lungs – all the trauma we induced when they were already poorly formed
    o Can lead to bronchopulmonary dysplasia
  • Intracranial hemorrhages
    o Intraventricular – enlarged ventricles – hydrocephalus/ if obstructive might get raised ICP, may need a VP shunt. If it bled into the parenchyma – causes cerebral palsy
  • Hypoxia = hypoxic-ischaemic encephalopathy- can lead to cerebral palsy, epilepsy and hearing loss

Paediatrics (11 decks)

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