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Medicine, Year 4, Paediatrics > Neonatology > Flashcards

Neonatology Flashcards

1
Q

Outline briefly the process of excreting Bilirubin

A
  1. Red blood cells break down to release unconjugated bilirubin
  2. Unconjugated bilirubin becomes conjugated via the liver
  3. The conjugated bilirubin can be excreted into the urine, or into bile and thus into the stool
  4. Some of the bile excreted is reabsorbed into small intestine
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2
Q

Outline physiological jaundice:

  • When it presents
  • When babies is it most commonly seen in
  • Pathophysiology
  • When does it resolve
A

Physiological jaundice presents at around days 2-7, and is more commonly seen in breast fed babies.

Caused by 1. High concentration of more fragile RBCs which haemolyse 2. Underdeveloped liver 3. No placental access as it normally is excreted via this means

Resolves completely by day 10

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3
Q

What investigation should be done in babies showing jaundice in the first 24 hours?

A

Jaundice within 24 hours of birth is always pathological: Serum bilirubin within 2 hours

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4
Q

Why does jaundice occur in premature neonates? What type of billirubin causes the jaundice?

A

Physiological jaundice is exaggerated in premature neonates due to an immature liver

Tends to be unconjugated

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5
Q

What is a serious complication of raised billirubin? Outline its clinical presentation

A

Kernicterus

High levels of bilirubin crosses the BBB, and causes damage to the CNS. Patients may appear less responsive, floppy, drowsy, poor feeding. This can lead to cerebral palsy, learning difficulties and deafness

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6
Q

What are some reasons for “Breast Milk Jaundice”?

A
  • Components of breast milk can inhibit liver’s ability to process bilirubin
  • Breast fed babies are more likely to dehydrate if feeding poorly. Poor feeding will delay passage of stools and cause increased bilirubin absorption from intestine
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7
Q

What is prolonged jaundice defined as?

A

> 14 days in full term babies, and >21 days in premature babies

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8
Q

Causes of neonatal jaundice can be split into increased production or decreased clearance. Give examples of conditions which cause increased production of Bilirubin

A

Increased production:

  • Haemolytic disease of Newborn
  • ABO Incompatibility
  • Haemorrhage
  • Cephalo-haemorrhage
  • Polycythaemia
  • Sepsis / DIC
  • G6PD Deficiency
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9
Q

What are investigations one might order for a baby with neonatal jaundice?

A
  • FBC, Blood film for polycythaemia / anaemia
  • Conjugated bilirubin (for suspecting biliary atresia)
  • Blood type testing (for Rh/ABO incompatibility)
  • Direct Coombs test (for haemolysis)
  • TFTs (for hypothyroidism)
  • Blood / urine culture (for sepsis)
  • G6P levels (for G6PD deficiency)
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10
Q

What is the management for jaundice?

A
  • Total bilirubin is monitored / plotted on a treatment threshold chart, with age of baby on x-axis and bilirubin level on y-axis. If total bilirubin reaches threshold, then treat
  • Phototherapy is usually adequate, which converts unconjugated bilirubin into isomers which get excreted without liver conjugation. During treatment, bilirubin is measured and a rebound bilirubin should be taken 12-18 hours later
  • If extremely high levels of bilirubin, consider exchange transfusion instead
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11
Q

When should the APGAR score be calculated?

A

At 1min, 5min and 10mins

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12
Q

What does the APGAR score comprise of? What is the minimum and maximum scores?

A
  • A - Appearance
  • P - Pulse
  • G - Grimace
  • A - Activity (muscle tone)
  • R - Respiration

Measured from 0 to 10

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13
Q

Why is hypoxia something to worry about in neonates during birth?

A

Contractions, normal labour and birth can lead to hypoxia. Hypoxia can lead to bradycardia, reduced consciousness and reduced respiratory effort. Complications of hypoxia include Hypoxic-Ischaemic Encephalopathy which can lead to cerebral palsy

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14
Q

Outline the APGAR Scoring system

A

Appearance:
0 = Blue / pale centrally
1 = Blue extremities
2 = Pink

Pulse:
0 = Absent
1 = <100
2 = >100

Grimace:
0 = No response
1 = Little response
2 = Full response

Activity:
0 = Floppy
1 = Flexed arms / legs
2 = Active

Respiration
0 = Absent
1 = Slow / irregular
2 = Strong / crying

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15
Q

If a baby is not breathing, how many breaths can be given initially? What about after?

A

5 ventilation breaths, which can be repeated for 2 cycles. If still no response, can give 30 seconds of ventilation breaths later

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16
Q

When might you start chest compressions on a neonate?

What is the compression:breath rate?

A

If they do not respond to ventilation breaths and their HR drops below <60 / min, then commence chest compressions at a rate of 3:1 compression:breaths

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17
Q

What are the benefits of delayed umbilical cord clamping?

A

Improves Hb, iron stores, BP

Reduces likelihood of intra-ventricular haemorrhage and necrotising enterocolitis

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18
Q

What is the possible downside of delayed cord clamping?

A

Neonatal jaundice - may require more phototherapy

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19
Q

What is the significance of Vitamin K given to neonates?

A

Most neonates are deficient in Vitamin K. IM injection, reduces likelihood of bleeding (intracranially, from umbilical stump and gastrointestinal)

Can be given orally, however must be given at birth, at 7 days and at 6 weeks

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20
Q

What is SIDS? When does it occur?

A

Sudden Infant Death Syndrome, occurs before the age of 1. Commonly occurs before 6months, with a peak between 2-4 months

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21
Q

What are the five major risk factors for SIDS?

A
  • Sleeping prone
  • Parental smoking
  • Prematurity
  • Bed sharing
  • Hyperthermia
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22
Q

What are some ways of risk minimisation for SIDS?

A
  1. Put baby supine when not supported
  2. Keep head uncovered
  3. Place feet at foot of bed to prevent sliding down
  4. Avoid handling babies after smoking
  5. Keep cot clear of toys / blankets
  6. Maintain temperature of 16-20C
  7. Avoid co-sleeping
  8. Avoid smoking
  9. If co-sleeping, avoid alcohol, drugs, smoking, sleeping tablets or deep sleepers
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23
Q

How is prematurity defined? What are the subtypes of prematurity?

A

Prematurity is defined as less than 37 weeks gestation. 32-37 weeks is moderate to late pre-term
28-32 weeks is very pre-term
<28 weeks is extreme pre-term

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24
Q

What are some things which can be done for a woman with a history of premature births or shows a cervical length less than 25mm before 24 weeks?

A
  • Prophylactic vaginal progesterone suppository

- Prophylactic cervical cerclage

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25
Q

What are some things which can be done for a woman already showing signs of preterm labour?

A
  1. Tocolysis (anti-contraction medications) with Nifedpidine
  2. Maternal corticosteroids (before 35 weeks)
  3. IV Magnesium Sulphate (before 34 weeks, protects babies brain)
  4. Delayed cord clamping
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26
Q

Define:

  • Small for Gestational Age
  • Normal
  • Large for Gestational Age
A

Small for Gestational Age: < 10th centile
Normal: 10th to 90th centile
Large for Gestational Age: >90th centile

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27
Q

What would you do if you notice a child is Small for Gestational Age on a Newborn Exam?

A

Plot their head circumference to determine if it is symmetrical (head is proportionally smaller) or asymmetrical (low weight, head circumference preserved)

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28
Q

What is the prognosis of cranial moulding?

A

Will resolve within a few days

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29
Q

What might a bulging fontanelle suggest?

A

Raised ICP

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30
Q

What might a sunken fontanelle suggest?

A

Dehydration

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31
Q

Shoulder dystocia is associated with what fracture?

A

Clavicle fracture

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32
Q

What is normal respiratory rate and heart rate in a newborn?

A

Respiratory rate: 30 - 60 per min

Heart rate: 120 - 150 beats per min

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33
Q

What is the normal size of a penis in a newborn?

A

Atleast 2cm

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34
Q

What does white vaginal discharge in a newborn suggest?

A

Normal, due to maternal oestrogens

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35
Q

How are pre-ductal and post-ductal oxygen readings taken?

A

Pre-ductal: Right wrist

Post-ductal: Either foot

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36
Q

What is the Sucking Reflex seen in newborns?

A

Newborn will instinctively suck anything that touches the roof of mouth

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37
Q

What is the Rooting Reflex seen in newborns?

When does it dissapear?

A

Newborn’s head will turn in the direction of which their cheek was stroked. Present at birth, disappears within 4 months

38
Q

What is the Stepping Reflex seen in newborns?

A

When soles of feet touch the floor they will instinctively try to walk

39
Q

What is the Moro Reflex seen in newborns?

A

When supporting infants upper back with one hand, and then dropping back will cause the head and legs to extent and the arms will jerk upwards. Arms will then be brought together and hand will clench into a fist and child will cry

40
Q

Why might the Moro Reflex be asymmetrical?

A

Brachial plexus injury, hemiparesis, fractured clavicle

41
Q

When should the newborn examination be performed?

A

Within 72 hours and repeated at 6-8 weeks by GP

42
Q

What are the three main extracranial injuries causing a haematoma?

A

Caput succedaneum
Subgaleal haemorrhage
Cephalohaematoma

43
Q

What of the three extracranial injuries cause a haematoma that crosses the suture lines? Why does it cross suture lines?

A

Caput succedaneum
Subgaleal haemorrhage

Crosses suture lines because the haematoma is above the level of the periosteum

44
Q

What is the prognosis of Caput succedaneum?

A

Resolves within a few days

45
Q

Where does Caput succedaneum typically form?

A

Over the brain vertex

46
Q

Where does Cephalohaematoma typically form?

A

Commonly in the parietal region

47
Q

What is the prognosis of Cephalohaematoma?

A

Resolves within a few months

48
Q

Does cephalohaematoma cross the suture lines? Why / why not?

A

No, as it is located beneath the periosteum

49
Q

What are some complications of cephalohaematoma?

A

Jaundice and anaemia

50
Q

What is Erb’s Palsy? What is the typical finding?

A

Damage to the C5/C6 nerve fibres in the brachial plexus, associated with shoulder dystocia, traumatic or instrumental delivery

Typically find a “Waiter’s tip” appearance

  • Internally rotated shoulder
  • Extended elbow
  • Flexed wrist facing backwards
  • Lack of movement in affected arm
51
Q

What is the prognosis of Erb’s Palsy?

A

Function normally returns spontaneously within a few months. If function does not improve, will require surgical input

52
Q

What is the management of Hypoxic-Ischaemic Encephalopathy?

A

Therapeutic Hypothermia (33-34 degrees) measured rectally. Cooled for 72 hours followed by a gradual heating for 6 hours

53
Q

What is the significance of Sarnat Staging?

A

Classification for Hypoxic Ischaemic Encephalopathy

54
Q

Define the “neonatal” period

A

From birth to 1 month

55
Q

What are common causes of Neonatal Sepsis?

A
  • Group B Streptococcus
  • E. Coli
  • Listeria
  • Klebsiella
  • Staphylococcus aureus
56
Q

What are some risk factors of Neonatal Sepsis?

A
  • Vaginal GBS colonisation
  • Sepsis in previous baby
  • Maternal sepsis, Chorioamnionitis, Fever >38C
  • Prematurity (< 37 weeks)
  • Premature rupture of membranes
  • Prolonged rupture of membranes
57
Q

What are some clinical features and red flags of Neonatal Sepsis?

A

Clinical Features

  • Fever
  • Hypoxia
  • Tachycardia / Bradycardia
  • Poor feeding
  • Hypoglycaemia
  • Respiratory distress
  • Jaundice within 24 hours of birth
  • Vomiting

Red Flags

  • Confirmed / suspected sepsis in mother
  • Signs of shock
  • Seizures
  • Term baby needing mechanical ventilation
  • Respiratory distress >4 hrs after birth
  • Presumed sepsis in another baby in a multiple pregnancy
58
Q

How do you manage a child with Neonatal Sepsis?

A
  • If 1 risk factor/feature -> Observe for 12 hours
  • If 2 risk factor/feature -> Start ABX within 1 hr of decision
  • If 1 red flag -> Start ABX within 1 hr of decision

Antibiotics

  • Benzypenicillin & Gentamycin
  • Cefotaxime if low risk

Investigations

  • Blood cultures (before giving ABX)
  • Lactate
  • CRP
  • Urine Output
  • Consider LP if signs of Meningitis
59
Q

The effects of alcohol on a foetus is greatest when?

A

In the first 3 months of pregnancy

60
Q

What are the dysmorphic features of Foetal Alcohol Syndrome?

A
  • Microcephaly
  • Thin upper lip
  • Smooth, flat philtrum
  • Short palpebral fissures
  • Learning difficulties
  • Behavioural difficulties
  • Hearing & vision problems
  • Cerebral palsy
61
Q

How can we prevent Congenital Rubella Syndrome is a woman planning to become pregnant?

A

Give the MMR Vaccine across 2 doses 3 months apart

62
Q

Can pregnant women have the MMR vaccine?

A

No, it is a live vaccine

63
Q

What are four features of Congenital Rubella Syndrome?

A

Congenital cataracts
Congenital heart disease (PDA, Pulmonary stenosis)
Learning disabilities
Hearing loss

64
Q

What are the harms to the mother if she is pregnant and has an infection with Varicella Zoster Virus for the first time?

A

Can cause varicella pneumonitis, hepatitis, encephalitis

65
Q

A woman gets pregnant and comes into contact with someone who has chickenpox, however she has had chickenpox before. What does this mean?

A

She is immune and safe

66
Q

A woman gets pregnant and comes into contact with someone who has chickenpox, however is unsure if she has had chickenpox before. What does this mean?

A

If in doubt, check igG levels for VZV

If positive, she is immune
If negative, give IV varicella immunoglobulins as prophylaxis within 10 days of exposure

67
Q

A woman gets pregnant and comes into contact with someone who has chickenpox. She develops a rash. What does this mean?

A

Give oral acyclovir if presents within 24 hours and >20 weeks gestation

68
Q

What are the features of Congenital Varicella Syndrome

A
  • Foetal growth restriction
  • Microcephaly
  • Hydrocephalus
  • Learning disabilities
  • Scars and significant skin changes in a dermatomal distribution
  • Limb hypoplasia
  • Chrorioretinitis
69
Q

What is the classic triad for Congenital Toxoplasmosis?

A

Intracranial calcification
Hydrocephalus
Chorioretinitis

70
Q

Causes of neonatal jaundice can be split into increased production or decreased clearance. Give examples of conditions which cause decreased clearance of Bilirubin

A
  • Prematurity
  • Breast milk jaundice
  • Extrahepatic biliary atresia
  • Endocrine (Hypothyroidism, Gilberts, Crigler-Najjar)
71
Q

Retinopathy of Prematurity affects what groups of babies?

A 
Premature babies (born before 32 weeks)
Low birth weight babies
72
Q

Why does Retinopathy of Prematurity affect premature babies? Outline the pathophysiology

A

Retinal blood vessel formation begins at 16 weeks and completes by 37-40 weeks. Vessel formation is stimulated by a hypoxic environment. When a baby is born premature, part of their care includes supplementary oxygen which removes the stimulus for retinal blood vessel formation

When the hypoxic environment returns, neovascularisation occurs as well as scar tissue formation. These abnormal blood vessels may regress, leading the retina without a blood supply, and the scar tissue can cause retinal detachment

73
Q

Outline the stages of Retinopathy of Prematurity

A 
Stage 1: Demarcation line forms
Stage 2: Demarcation line widens and thickens
Stage 3: New blood vessel formation
Stage 4: Partially detached retina
Stage 5: Retinal detachment

Plus disease: Additional findings i.e. torturous vessels and hazy vitreous humour

74
Q

What babies should be screened for Retinopathy of Prematurity? Who performs the screening?

A
  • Babies with a weight below 1.5kg
  • Babies born before 32 weeks

Performed by an Opthalmologist

75
Q

What is the first-line management for Retinopathy of Prematurity?

A

Transpupillary laser photocoagulation

76
Q

List some substances which can cause Neonatal Abstinence Syndrome (NAS)

A
  • SSRIs
  • Alcohol
  • Methadone
  • Cocaine
  • Opiates
  • Nicotine / Cannabis
  • Amphetamines
  • Benzodiazepines
77
Q

What is the onset of NAS Symptoms for Opiates, Diazepam, SSRIs, Alcohol?

A

3 - 72 hours

78
Q

What is the onset of NAS Symptoms for Methadone, Benzodiazepines?

A

24 hours - 21 days

79
Q

What are some CNS, Vasomotor / Respiratory, Metabolic / GI signs and symptoms of Neonatal Abstinence Syndrome?

A

CNS:

  • Irritability
  • Hypertonia
  • High pitched cry
  • Not settling
  • Tremors
  • Seizures

Vasomotor / Respiratory:

  • Yawning
  • Sweating
  • Unstable temperature
  • Pyrexia
  • Tachypnoea

Metabolic / GI:

  • Poor feeding
  • Vomiting
  • Hypoglycaemia
  • Loose stools
  • Sore nappy area
80
Q

What is the non-medical and medical management for Neonatal Abstinence Syndrome?

Any other additional considerations?

A

Non-medical:

  • Mothers known to use substances have an alert documented in their notes
  • Babies monitored for 3 days using a NAS Chart (2 days if SSRIs)
  • Urine sample collection
  • Quiet, dim environment with gentle handling

Medical:

  • Morphine sulphate for opiate withdrawal
  • Phenobarbitone for non-opiate withdrawal
  • Gradually wean off medication

Additional considerations:

  • Hep B, Hep C, HIV testing
  • Safeguarding, social services involvement
  • Safety netting advice if withdrawal symptoms occur
  • Follow up from paediatrics, social services, GP, health visitor
  • Support for mother for drug cessation
  • Check suitability for breast feeding
81
Q

What is Apnoea defined as?

A

Cessation of breathing for 20 seconds or short periods with O2 desaturation / bradycardia

82
Q

How is Apnoea of Prematurity treated?

A

Apnoea monitors are attached to premature babies, and will make a sound when apnoea occurs. There may be tactile stimulation to restart breathing. IV caffiene may also be used to prevent apnoea / bradycardia

83
Q

In one sentence, describe Gastroschisis

A

Gastroschisis refers to when the anterior abdominal wall fails to close during foetal development, causing the abdominal organs to protude out

84
Q

What are the risk factors for Gastroschisis?

A

Young Maternal Age
Alcohol use during pregnancy
Smoking during pregnancy

85
Q

In Gastroschisis, is there a peritoneal layer covering the abdominal organs? If, so, is there any implications?

A

No peritoneal layer - hence organs are exposed to amniotic fluid and intestines can become irritated and inflamed, causing malabsorption issues later

86
Q

In Omphalocele, is there a peritoneal layer covering the abdominal organs?

A

Yes there is a peritoneal layer covering the abdominal organs

87
Q

Where is the Gastroschisis classically located?

A

Right of the umbillicus

88
Q

What is the management of Gastroschisis?

A
  • Cover bowel with cling film, as no peritoneal layer
  • Immediate surgery to repair defect
  • TPN nutrition
89
Q

What is the management of Omphalocele?

A
  • Gradual surgery over several months, to reduce likelihood of respiratory complications
90
Q
  1. What is a Congenital Diaphragmatic Hernia?
  2. What is a Congenital Diaphragmatic Hernia caused by?
  3. How does the abdomen appear in a child with Congenital Diaphragmatic Hernia?
  4. What are the immediate consequences of an infant being born with Congenital Diaphragmatic Hernia?
  5. What is the most common type of Congenital Diaphragmatic Hernia?
  6. Prognosis of Congenital Diaphragmatic Hernia is dependent on what?
  7. What is the prognosis of a Congenital Diaphragmatic Hernia after treatment?
A
  1. The herniation of the abdominal viscera into the chest cavity due to incomplete formation of the diaphragm
  2. Failure of the pleuroparietal canal to close completely
  3. Concave appearance
  4. Can cause pulmonary hypoplasia and pulmonary hypertension. This can lead to respiratory distress in infants
  5. Left-sided, posterolateral Bochdalek hernia - 85% of cases
  6. Liver position → if in thoracic cavity, poor prognosis and Head-to-lung ratio → If >1, good prognosis
  7. Only 50% survive despite surgical intervention

Medicine, Year 4, Paediatrics (16 decks)

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