Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

Coovadias Paediatrics > Neonatology > Flashcards

Neonatology Flashcards

1
Q

How does the neonate physiologically prepare for breathing?

A
  1. Incr cortisol, TSH, catecholamines -> surfactant production + process to clear lung fluid starts
  2. Maturation of the brain’s respiratory centre
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the cardiovascular changes from the neonate to the postnate?

A
  1. Decr pulmonary vascular resistance
  2. Ductus venosus
  3. Incr systemic resistance
  4. Shunt reversal
  5. Ductus arteriosus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What does the umbilical artery become in the postnate?

A 
Patent = superior vesicle arteries
Obliterated = medial umbilical ligaments
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are the metabolic changes from the neonate to the postnate?

A

Gluconeogenesis

Glycogenolysis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Name foetal risk factors for poor adaption of the neonate to extrauterine life

A 
Foetal distress
Meconium stained liquor
Premature
Post-term
IUGR
Multiple birth
Abnormal presentation
Shoulder dystocia
Assisted delivery
Infection
Congenital malformation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Name maternal risk factors for poor adaption of the neonate to extrauterine life

A 
Pre-eclampsia
Chronic hypertension
Diabetes
Infection
Drug use
Polyhydramnios
Oligohydramnios
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Name placental risk factors for poor adaption of the neonate to extrauterine life

A

Chorioamnionitis
Abruptio placenta
Placenta previa
Cord prolapse

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Discuss the APGAR score

A

Activity Pulse Grimace Appearance Resp

  1. Heart rate
    - absent (0)
    - <100bpm (1)
    - >100bpm (2)
  2. Respiration
    - absent (0)
    - slow, irregular (1)
    - regular, cry (2)
  3. Muscle tone
    - limp (0)
    - some flexion of extremities (1)
    - active movement (2)
  4. Response to stimulation
    - no response (0)
    - grimace (1)
    - cough, sneeze, cry (2)
  5. Colour
    - blue/pale (0)
    - body pink extremities blue (1)
    - pink (2)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are the ABCDs of neonatal resuscitation?

A 
Anticipate high risk pregnancies
Assessment after delivery
Airway management
Breathing
Circulation
Drugs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Name consequences of asphyxia

A 
Acute
CNS
- apnoea
- seizures
Renal
- ATN
Adrenal
- haemorrhage
- failure
Cardiac
- ischaemia
Lung
- PPHN
GIT
- delayed transit
- NEC
Liver
- hepatic dysfunction

Chronic

  • CP
  • epilepsy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Name maternal risk factors for a high risk pregnancy

A 
Age
Diabetes
Hypertension
Anemia
Renal disease
Infection
Drugs
Substance abuse
Unbooked
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Name fetal risk factors for a high risk pregnancy

A 
Congenital anomaly
Multiple gestation
Prematurity
Bradycardia
IUGR
Placenta abruptio/praevia
Polyhydramnios
Oligohydramnios
IUGR
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Name labour and delivery risk factors for a high risk pregnancy

A 
Abnormal CTG
MSL
PROM
Cord prolapse
Abnormal presentation
Prolonged labour
Emergency C/S
Narcotic drugs
GA
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Which 3 vital signs must be assessed?

A

Breathing
Colour
Heart rate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Differentiate primary vs secondary apnoea

A 
Primary = HR >100; recovery spontaneous
Secondary = HR<100; no recovery without resus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is crucial to assess in the newborn resus algorithm?

A

Term gestation
Breathing
Good tone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is routine care with the mother?

A

Dry the baby
Place skin to skin
Cover with a dry linen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

How do you manage the newborn that is missing any of the 3 crucial assessment objectives?

A

Move to radiant warmer for further management

  1. Stabilise
    - warm
    - position airway ‘sniffing’
    - clear secretions
    - dry
    - stimulate
  2. Ventilate
    - free flow oxygen
    - positive pressure
  3. Chest compressions
  4. Adrenaline w/wo volume expansion
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What gestational age should not be dried at birth? What is the alternative?

A

<30 weeks gestation

Wrap preterm baby’s torso in plastic bag

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What is ‘the golden minute’

A

60s to stabilise, re-evaluate and start ventilation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What is assessed in the breathing step of the newborn resus algorithm?

A

Assess breathing/crying and/or heart rate

Gasping, apnoeic, persistent central cyanosis despite 100% oxygen or HR<100 = next step!

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

How do you maintain normothermia in the newborn?

A 
Environment must be 24-26 degrees
Put on radiant warmer before dilvery
Close doors and windows
Dry baby
Remove wet linen
Thermal mattress
Head cap
Plastic bag
Humidified resus gases
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Neonates below what values are at high risk of hypothermia?

A

<1500g

<32 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What is newborn hypothermia associated with?

A

Respiratory distress
Hypoglycemia
Late-onset sepsis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
When do you perform suctioning?
Obvious obstruction to spontaneous breathing
26
When do you perform suction in MSL newborns?
If infant is non-vigorous
27
Discuss how you would approach suctioning the infant with a catheter
Mouth BEFORE nose | Rule of 5
28
What is the rule of 5?
Suction catheter passed to the depth of no more than 5cm for 5 seconds
29
What can overzealous suctioning cause?
Laryngospasm Bradycardia Minor abrasions -> infection
30
How can you stimulate the newborn?
Dry Rub the back Flick the soles of the feet
31
What are the methods of free flow oxygen delivery to the newborn?
Hand cupped Funnel Mask
32
Name 2 assisted ventilation devices and which is best?
Ambubag | T-piece resuscitator = best (can control amount)
33
Compare rim masks with round masks
Rim mask - conforms to shape of face (better seal) - less pressure required (safer for eyes) Round mask - don't need to inflate rim - danger of pressure on the eyes if large
34
What technique must you use to apply the mask to the face?
C E
35
How do you know your ventilation is effective?
HR improvement Effective chest expansion Colour improvement
36
Name common causes of ineffective ventilation
Poor head position Airway obstruction Poor mask application Faulty bag
37
What is the acronym to ensure adequate ventilation?
``` MR SOPA Adjust face MASK to assure good seal REPOSITION airway SUCTION mouth and nose OPEN mouth slightly and move jaw forward PRESSURE increase to achieve chest rise AIRWAY alternative (ETT/laryngeal mask) ```
38
What is the best indicator of successful oxygenation?
Heart rate
39
How can you assess heart rate?
3 lead ecg (gold standard) Saturation monitor Auscultation
40
What oxygen saturation do you start infants at?
Term - 21% (room air) Preterm - 21%-30%
41
How do you measure pre-ductal sats?
Right hand/ear
42
What are normal pre-ductal sats after birth?
``` 1min >60% 2min >65% 3min >70% 4min >75% 5min>80% >10min 90-95% ```
43
What are indications for neonatal intubation?
Ineffective bagmask Prolonged ventilation Need for compressions
44
Should you use an ETT or laryngeal mask for neonatal intubation?
ETT first | If unsuccesful/unfeasible and neonate >34w -> laryngeal mask
45
Which blade should you use on your laryngoscope in neonates?
Straight blade
46
Do neonatal ETT have inflatable cuff?
No
47
How do you verify correct tracheal tube placement?
Symmetrical chest movement Auscultation (breathing sounds all lung fields) Condensation Improvement in colour, HR and activity
48
What is the formula for tube depth?
Weight (kg) + 6 = _cm at the lip
49
Discuss tube sizes required for infants of varying weight
``` <1000g = 2.5 1000g-2000g = 3.0 2000g-3000g = 3.5 3000g-4000g = 4.0 ```
50
How often should you assess your infant's breathing, HR, colour and sats?
Every 30-60s
51
What do you do if HR<100?
Start PPV
52
What do you do if HR<60?
3:1 compressions over 2 seconds repeated
53
What are the techniques for chest compressions in infants and which is superior?
Hand encircling Two finger Hand encircling is better as it generates higher BP and results in less rescuer fatigue
54
What is the rule of 3?
Compressions at lower 1/3 baby sternum Compress to 1/3 baby chest 3 compression:1 breath
55
What is the preferred route of IV access in neonates?
Umbilical vein
56
What do you do if HR <60 despite adequate ventilation and chest compressions?
Give adrenaline
57
What is the dose for normal saline?
10ml/kg IV over 5-10min
58
What is the dose for dextrose?
2-3ml/kg IV 10% dextrose
59
When should you not start resus?
Futile - dead baby - lethal anomaly Poor prognosis - BW<500g - trisomy 13 - trisomy 18 - severe hydocephalus - single ventricle
60
When do you stop resus?
After 10min continuous and adequate resus if HR undetectable
61
When do you stop resus?
After 10min continuous and adequate resus if HR undetectable
62
What should you do as part of routine post-delivery care?
Vitamin K Antibacterial eye ointment Umbilical cord care
63
What should you do at the postnatal follow up?
Surveillance of growth and development Immunisation Hearing screen
64
What should you do at the postnatal follow up?
Surveillance of growth and development Immunisation Hearing screen
65
Define a birth injury
Traumatic event at birth causing structural destruction or functional deterioration of the neonate’s body
66
Name risk factors for birth injuries
``` Macrosomia Prematurity Instruments (forceps, vacuum) Abnormal presentation Precipitous delivery ```
67
Name kinds of birth injuries
``` Soft tissue Cranial Nerve Fractures Intra-abdominal Subconjunctival haemorrhage ```
68
Name soft tissue birth injuries
``` Erythema Abrasions Petechiae Ecchymoses Bruising Subcutaneous fat necrosis Lacerations ```
69
Compare localised vs generalised petechiae in infants
Localised - due to sudden increase in venous pressure -> pinpoint capillary rupture - resolves spontaneously Generalised - investigate
70
Name risk factors for subcutaneous fat necrosis
Perinatal asphyxia Cold exposure Trauma
71
How long does subcutaneous fat necrosis take to resolve?
6-8 weeks
72
What is a child with subcutaneous fat necrosis at risk of developing?
Hypercalcemia up to 6months
73
Discuss management of laceration birth injuries
``` Superficial = adhesive tape, keep clean Deep = suture ```
74
Name cranial injuries
Extracranial - skull moulding - caput succedaneum - cephalhaematoma - subgaleal haemorrhage Intracranial - subdural haemorrhage - epidural haemorrhage - subarachnoid haemorrhage - intraventricular haemorrhage
75
How long does moulding take to resolve?
Days
76
What are the layers of the scalp?
``` SCALP Skin and dense Connective tissue Aponeurosis (epicranial) Loose areolar connective tissue Periosteum ```
77
Discuss management of caput succedaneum
Improves 48-72 hours and resolves in 4-6days No treatment Not resolving -> investigate
78
What is cephalhaematoma associated with?
Vacuum delivery
79
How long does cephalhaematoma take to resolve?
3-4 weeks | Calcifies up to 4 months
80
Compare the different extracranial injuries
Caput = soft oedema Cephalhaematoma = subperiosteal bleeding Subgaleal bleed = subaponeurotic bleeding
81
What limits the bleeding of a subgaleal haematoma?
Orbital ridges anteriorly Temporal fascia laterally Nape of neck posteriorly
82
What are infants with subgaleal haematoma at risk of developing?
Hypovolemic shock (can lose substantial blood volume)
83
How do you observe an infant with subaponeurotic haemorrhage?
Serial head circumference Hb Vital signs
84
What are all infants with a bleeding injury at risk for?
Jaundice
85
Discuss management of a subaponeurotic haemorrhage
Pain relief Volume resus RBC/FFP transfusion
86
Name signs of intracranial birth injury
Bulging fontanelle Hypotonia Seizures Decr LOC
87
Which nerve injuries are common birth injuries?
Facial nn Brachial plexus Phrenic nn
88
Does facial nerve injury resolve spontaneously or require treatment?
Resolves within 2-3 weeks
89
Name signs of facial nerve injury
Loss of nasolabial fold Ptosis Corner of mouth drooping Mouth drawn to unaffected side
90
Name risk factors for brachial plexus injury
Shoulder dystocia Macrosomia Breech presentation Instrument assisted deliveries
91
What is the most common type of brachial plexus injury?
Erb-Duchenne palsy (C5-6)
92
How does a child with Erb-Duchenne palsy appear?
Arm in adduction, internal rotation, fully extended at elbow, pronated forearm and flexion of wrist Intact grasp reflex Assymetrical Moro
93
Name the types of brachial plexus injury
Erb-Duchenne (C5-6) Klumpke (C8-T1) Total arm paralysis Horner syndrome
94
How does a phrenic nerve injury occur?
Damage C3-C5 Impaired diaphragm Ineffective respiration Assoc arm weakness
95
How do you identify a phrenic nn injury on CXR?
Elevated diaphragm
96
Name fracture birth injuries
Clavicle Humerus Femur Skull
97
Name risk factors for clavicle fracture
Shoulder dystocia Macrosomia Instrument assisted delivery
98
What is the prognosis for clavicle fracture at birth?
Excellent | Heals 7-10 days
99
How will a child with a humerus fracture at birth appear?
``` Deformity Crepitus Overlying petechiae Absent arm movement Absent Moro ```
100
How do you treat a humerus fracture?
Immobilise arm in adduction 2-4w | Pain management
101
What is femur fracture associated with?
Breech delivery
102
Define neonatal encephalopathy
Disturbed neurological function in the first 28 days in infants born ≥ 35 weeks gestation
103
Name signs of neonatal encephalopathy
``` Abnormal state of consciousness Decreased spontaneous movements Resp difficulty Feeding difficulty Poor tone Abnormal posture Absent/partial primitive reflexes Seizures ```
104
Name causes of neonatal encephalopathy
``` Hypoxic ischaemic encephalopathy Perinatal stroke - maternal cocaine abuse - pre-eclampsia - prothrombotic disorders - congenital heart disease IVH Metabolic disorders - hyperammonemia - hypoglycemia - organic acidemia - amino acidemia - mitochondrial d/o - fatty acid metabolism d/o Withdrawal from maternal drugs - narcotics - alcohol - SSRIs - TADs Genetic - Prader Willi - chromosomal Structural brain anomalies Meningitis ```
105
Discuss how you determine the cause of neonatal encephalopathy
``` Clinical evaluation of neonate Maternal medical history Obstetric history Intrapartum factors Blood gas within 1hr of birth Multi-organ dysfunction Neuroimaging EEG ```
106
How do you diagnose HIE?
1. Abnormal clinical signs 2. Contributing events in close temporal proximity to labour and delivery (sentinel event) 3. Developmental outcome (long term) – spastic quadriplegia or dyskinetic CP
107
Name pre-conceptual and conceptual risk factors for HIE
Maternal age >35yo Family hx of seizures/neurological disease Infertility treatment Prev neonatal death
108
Name antepartum risk factors for HIE
``` Maternal prothrombotic/proinflammatory disorder Maternal thyroid disease Severe preeclampsia Chorioamnionitis Multiple gestation Genetic abnormality Congenital malformations IUGR Trauma Breech APH ```
109
Name intrapartum risk factors for HIE
``` Abnormal CTG Thick meconium Assisted vaginal delivery GA Emergency C/S Abruptio placenta Cord prolapse Uterine rupture ```
110
Name postnatal risk factors for HIE
Pulmonary disease Neurological disease Cardiovascular disease
111
Name labour and delivery risk factors for HIE
``` Maternal - cardiac arrest - asphyxiation - hypovolemic shock - status epilepticus Uteroplacental - abruptio placenta - cord prolapse - uterine rupture - hyperstimulation of uterus with oxytocics Foetal - fetomaternal haemorrhage - twin to twin transfusion syndrome - cardiac arrythmias in utero ```
112
What are signs that the encephelopathic event was acute peripartum or intrapartum?
APGAR <5 at 5 and 10min Fetal umbilical aa acidemia (pH <7 or base deficit >12) Multisystem involvement Neuroimaging evidence of acute brain injury
113
Which organs can be involved in HIE?
``` Renal - acute kidney injury -Hepatic - elevated liver enzymes Cardiac - decr CO -> low BP Haematological - low platelets - coagulopathy - DIC GIT - NEC Metabolic - hyponatremia (SIADH) - hypocalcemia ```
114
What is the long term outcome of hypoxic insult according to gestational age?
26-36 weeks Ischaemia - periventricular white matter - spastic diplegia >36 weeks Partial asphyxia - parasagittal watershed areas w/wo cortex - behavioural problems, language delays, cognitive deficits, possible epilepsy, severe motor impairment (rare) Acute total asphyxia - deep gray matter and peri-rolandic cortex - spastic quad CP - dystonic CP - cognitive
115
What is the long term outcome of partial asphyxia >36weeks?
``` Area: parasagittal watershed areas w/wo cortex Result - behavioural problems - language delays - cognitive deficits - possible epilepsy - severe motor impairment (rare) ```
116
What is the long term outcome of acute total asphyxia >36w?
``` Area:deep gray matter and peri-rolandic cortex Result - spastic quad CP - dystonic CP - cognitive - possible epilepsy ```
117
What is the long term outcome of ischaemia before 36 weeks?
``` Area: Periventricular white matter Result - spastic diplegia Why? Periventricular malacia increases risk of IVH which leads to spastic diplegia ```
118
Name deep grey matter
Basal ganglia | Thalamus
119
Name the constituents of the peri-rolandic cortex
Precentral gyrus Postcentral gyrus Paracentral lobule
120
What is the gold standard for identifing a hypoxic injury?
MRI
121
Discuss your management of HIE
``` Therapeutic hypothermia Supportive Neuroprotective - antiepileptics - EPO - melatonin - xenon ```
122
How soon must you start therapeutic hypothermia?
Best outcome - within 3 hours | Must be within 6 hours
123
What is the core temperature and duration of therapeutic hypothermia?
Core temp 33.5 - 34.5 | 72 hours
124
Discuss how you would determine the child's eligibility for cooling
``` A. Gestation age >36w AND <6hrs of age B. Physiological criteria - pH <7 or BD >16 - <5 APGAR 5 and 10min - ongoing resus from birth >10min C. Neurological criteria - moderate to severe encephalopathy - abnormal background/seizure activity on aEEG ```
125
Discuss the modified sarnat score for encephalopathy
``` Moderate encephalopathy LOC = lethargic Spontaneous activity = decr Posture = distal flexion, complete extension Tone = hypotonia Primitive reflexes - suck = weak - moro = incomplete Autonomic system - pupils = constricted - HR = bradycardia - resp = periodic ``` ``` Severe encephalopathy LOC = stupor/coma Spontaneous activity = none Posture = decerebrate Tone = flaccid Primitive reflexes - suck = absent - moro = absent Autonomic system - pupils = deviated/dilated/non-reactive - HR = variable - resp = apnoea ```
126
Why do we not cool deeper or for longer?
``` More side effects with no benefit (found in study) 120 hours - incr arrythmia risk - incr anuria risk - longer hospital stay 32 degrees - incr bradycardia risk - incr iNO use - incr ECMO need - more days on O2 ```
127
Name complications of therapeutic hypothermia
``` Sinus bradycardia Prolonged QT interval Systemic hypothermia Subcutaneous fat necrosis Thrombocytopenia ```
128
Discuss supportive management of encephalopathy
Control seizures - Phenobarbital, lorazepam, phenytoin, levetiracetam Exclude meningitis - LP
129
Which seizures can't an aEEG detect?
Short seizures Low amplitude seizures Focal discharges
130
When do you perform the MRI for HIE?
T1/T2/diffusion weighted | 24-96hrs post delivery and repeat >day 9
131
When do you perform a Thomson score and what does it predict?
Perform at birth Predicts outcome at 12months Good prognosis = <10 Poor prognosis = >15
132
Name minor abnormalities in the first few days of life
``` Peripheral cyanosis Subconjunctival haemorrhage Ebstein pearls Umbilical hernia Breast enlargement Neonatal menarche Vaginal discharge Hymen tags Positional talipes Nevus simplex Nevus flammeus Milia Miliaria Erythema toxicum neonatorum Transient pustular melanosis Dermal melanosis Transient vascular phenomena Sucking blisters Neonatal teeth Gingival cysts Polydactyly Preauricular skin tag Preauricular pit ```
133
What are Ebstein pearls?
Entrapped epithelium during palatal development -> 1-3mm at midline of palate
134
Which part of the palate are Ebstein pearls typically found?
Hard palate
135
Why do newborns experience breast enlargement?
Declining maternal oestrogen -> prolactin stimulation of newborn's pituitary gland
136
Why do female neonates sometimes experience white vaginal discharge?
Maternal hormone withdrawal
137
How do you differentiate positional talipes from talipes equinovarus?
Passively move the foot into neutral position Possible = positional Impossible = equinovarus
138
How is a club foot managed?
``` Non surgical - stretching - casting Surgical - tendons - ligaments - joints ```
139
What is another name for a club foot?
Talipes equinovarus
140
Do nevus simplex blanche when compressed?
Yes
141
What is nevus simplex?
Dilated superficial capillaries on eyelids, forehead, scalp and nape of neck
142
What do you need to exclude in a patient with nevus flammeus in opthalmic distribution of CNV?
Sturge Weber syndrome
143
What are milia?
Retention of keratin and sebaceous material in follicles -> pin sized on nose, cheeks and forehead
144
What are miliaria?
Retained sweat in obstructed eccrine glands -> pin sized vesicle on face, neck and chest
145
How can miliaria be prevented?
Avoid overheating
146
What is erythema toxicum neonatorum?
Small, white/yellow pustules on erythmatous base
147
When does erythema toxicum neonatorum appear?
Appears 1-3 days of life but can be present at birth
148
Where does erythema toxicum neonatorum appear?
Trunk, face, perineum, extremities | NEVER palms or soles!
149
What is transient pustular melanosis?
Superficial vesicopustular lesions with no erythmatous base
150
When does transient pustular melanosis appear?
Birth - weeks later | Ruptures within 48hrs and leaves hyperpigmented macules
151
What is another name for mongolian blue spots?
Dermal melanosis
152
Which population is dermal melanosis more common in?
African population
153
What is harlequin colour change and how does it appear?
Immature hypothalamic center -> lacks control of dilation of peripheral blood vessels Appears as erythema on dependent side of body with blanching of contralateral side
154
What is cutis marmorata and how does it appear?
Vascular response to the cold -> symmetrical reticulated mottling
155
How are neonatal teeth managed?
Remove if loose to prevent aspiration
156
What other anomalies should you look for in polydactly?
Trisomy 13 | Beckwith-Weideman syndrome
157
What abnormalities are associated with preauricular skin tags/pits?
Renal abnormalities -> perform renal sonar
158
Differentiate vomiting from regurgitation
``` Regurgitation = passive, effortless Vomiting = involuntary, active, forceful ```
159
What are you looking for on antenatal history in the vomiting child?
Pre-eclampsic toxemia (IUGR) Maternal infections Polyhydramnios Oligohydramnios
160
What is polyhydramnios in an infant that vomits an indication of?
Upper GI obstruction - atresia - stenosis
161
What is oligohydramnios in an infant that vomits an indication of?
Congenital renal abnormalities
162
What are you looking for on postnatal history in the vomiting child?
``` Birth hx - premature - HIE Onset Feeds Growth, weight, FTT Neurological signs - CP w/ bulbar weakness - raised ICP Respiratory signs - apnoea - strider - cystic fibrosis - recurrent aspiration - tracheosopheagel fistula Gastrointestinal - abdominal distension - stool characteristics (passage, colour) ```
163
What do children with CP with bulbar weakness often have?
Associated reflux
164
What are symptoms of oesophagitis?
Irritability Arching back Feed refusal Haematemesis
165
What are symptoms suggestive of cow's milk protein allergy?
Eczema | Diarrhoea
166
What is golden standard for GER?
pH manometry
167
GER vs GERD
GER is normal | GERD is a disease
168
Why can pH manometry test negative in infants?
Alkali reflux (not acidic)
169
Discuss management of GER
Non-pharmacological - position - smaller volumes more frequently - splitting feeds - feeds thickener Pharmacological - PPI (efficacy not established) Surgical - Nissan fundoplication
170
How can you categorise vomiting?
Bilious | Non-bilious
171
What are obstructive causes of non-bilious vomiting?
Obstruction above ampulla of vater - pyloric stenosis - upper duodenal stenosis - annular pancreas
172
What are non-obstructive causes of non-bilious vomiting?
``` Physiological - overfeeding - NGT placed incorrectly Infection - gastro - NEC - septicemia - UTI - meningitis CNS - incr ICP - intracranial bleed Endocrine - congenital adrenal hyperplasia Drugs - aminophylline - caffeine - neonatal abstinence syndrome Inborn error of metabolism Cow's milk protein allergy Decreased motility ```
173
What are causes of bilious vomiting?
``` Anatomical obstruction - small bowel stenosis/atresia - large bowel stenosis/atresia - imperforated anus - annular pancreas - volvulus Functional obstruction - Hirschprung's disease - meconium ileus ```
174
How do you approach the newborn with abdominal distension?
1. Intestinal obsutrction - functional vs mechanical 2. Ileus 3. Pneumoperitoneum
175
Which neonates usually have ileus?
Neonate with sepsis
176
What is the issue with hypokalemia in ileus?
Causes decreased peristalsis -> worsens the situation!
177
How do you manage ileus?
Rest the bowel NPO NGT decompression on bowel Identify and treat underlying cause
178
What do you look for on AXR to diagnose pneumoperitoneum?
Air under the diaphragm
179
How do you manage pneumoperitoneum?
NPO NGT decompression on bowel ABCs Surgery
180
How does UGIT obstruction present?
Polyhydramnios Vomiting (early) Abdominal distension (late) W/wo meconium passage
181
How does LGIT obstruction present?
Abdominal distension Delayed/absent meconium passage (early) Vomiting (late)
182
What is oesphaeal atresia usually associated with?
Trachea-oesophageal fistula
183
Name clinical features of oeophageal atresia
Polyhydramnios Incr frothy secretions Choking Cyanotic spells
184
How do you diagnose oesophageal atresia?
Place NGT and take CXR
185
Which condition is duodenal atresia associated with?
Trisomy 21
186
How do you diagnose duodenal atresia using AXR?
'Double bubble'
187
Name clinical features of pyloric stenosis
Visible peristalsis Olive-like mass in RUQ Hypochloremic, hypokalemic metabolic alkalosis
188
How do you diagnose pyloric stenosis?
U/S
189
When will a patient with pyloric stenosis present?
4-8weeks after birth
190
Which birth defect is more common: gastroschisis or omphalocele?
Omphalocele
191
Differentiate gastroschisis from omphalocele
Gastroschisis - right paraumbilical - no covering sac - free intestinal loops - NEC common Omphalocele - central - covering sac - firm mass - NEC uncommon
192
What anomalies is gastroschisis commonly associated with?
Intestinal atresia Malrotation Cryptorchidism
193
What anomalies is omphalocele commonly associated with?
Trisomy Cardiac defects BW syndrome Bladder extrophy
194
Which birth defect has a better prognosis: gastroschisis or omphalocele?
Gastroschisis
195
How do you manage gastroschisis clincally?
Silo bag to reduce gut into abdominal cavity
196
When is nephrogenesis complete?
34-36w
197
What is the renal function in the neonate's purpose?
Optimising retention > excretion | Low GFR which increases over the 1st year of life
198
What is CAKUT?
Congenital abnormalities of the kidney and urinary tract?
199
What is the differential diagnosis for unilateral hydronephrosis?
Pelviureteric junction obstruction | Vesicoureteric junction obstructioon
200
What is the differential diagnosis for bilateral hydronephrosis?
Bladder neck obstruction | Posterior urethral valves
201
What is the most common urinary tract abnormality in the neonate?
Unilateral hydronephrosis
202
Discuss polycystic kidney disease
``` Autosomal dominant - asx in childhood - presents in late adulthood w/ renal failure Autosomal recessive - neonatal period ```
203
What is the most common electrolyte abnormality encountered in newborns?
Dysnatremias
204
What are dysnatremias in the newborn assoc with?
Significant morbidity | Poor long-term neurological outcome
205
Define hyponatremia
Na <130mmol/l
206
Differentiate between the two forms of hypoatremia
Too much water - BP stable - normal skin turgor - weight stable Too little salt - BP decrease - poor skin turgor - weight decreased
207
What are causes of too much water in hyponatremia?
Excess fluid administration Cardiac failure Renal failure SIADH
208
What are causes of too little salt in hyponatremia?
Extra-renal salt loss | Congenital adrenal hyperplasia
209
What is the most common reason for hypernatremia?
Water deficit | Other: excess salt intake
210
What is the major cause of water deficit in hypernatremia in newborns?
Transepidermal fluid losses | Other causes: poor feeding
211
Why would a newborn have excess salt intake?
Formula feeding
212
Discuss the management of hypernatremia in the newborn
Calculate total body water deficit and replace over next 24-48hrs -> reduction of Na by 0.5-1mmol/l/hr
213
What risk is there if the sodium level is reduced too quickly in hypernatremia?
Cerebral oedema
214
Define hyperkalemia
K+ > 6.5mmol/l
215
What is the major risk of hyperkalemia?
Cardiac arrythmias
216
Name causes of hyperkalemia in the newborn
Renal impairment Excess potassium administration Congenital adrenal hyperplasia Incorrect test (haemolysed specimen)
217
What is a clinical feature of hypocalcemia in the newborn?
May present with neonatal seizures
218
Name causes of hypocalcemia
Maternal - hypothyroidism - vitamin D deficiency - diabetic Infant - HIE - DiGeorge syndrome
219
Other than hypocalcemia, what other electrolyte abnormality is often found in DiGeorge syndrome?
Hypomagnesemia
220
What is the most common bacterial infection in the neonatal period?
UTI | Boys > girls
221
Name risk factors for UTI in the newborn
Prem Caucasian CAKUT
222
Name common causative organisms of neonatal UTIs
Ecoli Enterobacter spp Klebsiella pneumonia
223
How do neonates with UTI present clinically?
``` Poor feeding Poor weight gain Pyrexia Vomiting Diarrhoea Lethargy Irritability Jaundice ```
224
What should you always look for in a neonate with sepsis?
UTI
225
What should you always look for in a patient with neonatal jaundice?
UTI
226
How do you diagnose UTI in the newborn?
1. Blood investigations - CRP - FBC 2. Urine specimen 3. Urine culture
227
Discuss the management of UTI in newborn
Empirical therapy until culture results come back IV broad spectrum antibiotic Avoid nephrotoxic ABs Renal U/S
228
Define acute kidney injury in the newborn
Abrupt decline in ability to clear waste products and to maintain fluid and electrolyte homeostasis
229
What is the KIDGO definition of AKI?
Incr in serum creatinine by 0.3g/dl Incr in serum creatinine by 1.5x baseline Urine output <0.5ml/kg/hr for 6hrs
230
What is the RIFLE criteria?
Used to classify kidney injury Risk of renal dysfunction (creatinine incr by 150%) Injury to the kidney (creatinine incr by 200%) Failure of kidney function (creatinine incr by 300%) Loss of kidney function (loss of function >4 weeks) End stage kidney disease (loss of function >3months)
231
Name causes of acute kidney injury in the newborn
Prerenal = decrease in renal blood flow to glomeruli - hypovolemia - decr CO - blood loos - HIE Renal - uncorrected prerenal -> ATN - congenital renal abnormality - renal vv thrombosis - nephrotoxins - infection Post renal = obstructive - congenital obstructive uropathy - neurogenic bladder
232
How should you evaluate a newborn you suspect has AKI?
``` History Examination Lab - UCE - CMP - urine analysis Imaging - U/S - doppler ```
233
How would you manage a newborn with AKI?
Supportive - maintain fluid balance - correct electrolytes - correct acidosis - treat hypertension - nutritional (avoid potassium, phosphates)
234
Which type of undescended testis is more common: unilateral or bilateral?
Unilateral (2/3) > bilateral (1/3)
235
What is an assoc abnormality of bilateral undescended testes?
Hypospadia
236
When should you refer undescended testes for surgery?
If undescended by 6months (gonadotropin surge at 3months) | Before 2 years
237
What are complications of an inguinal hernia in the newborn?
Strangulation Incarceration Need to correct surgically!
238
Discuss treatment of a hydrocele
No intervention | Resolves spontaneously
239
Give the components of a hypospadia
Ventral urethral meatus Hooded foreskin Chordee Ventral curvature
240
Provide the most common reason for congenital adrenal hyperplasia and discuss the features
21-hydroxylase deficiency -> 17-hydroxyprogesterone increase - decreased aldosterone - hyponatremia - hyperkalemia - decr cortisol in adrenal crisis with hypoglycemia - incr androgen production (female virilisation)
241
Discuss the presentation of a newborn in a salt-losing adrenal crisis
``` 1-3w of age Vomiting Weight loss Circulatory collapse Hypoglycemia Hyponatremia Hyperkalemia ```
242
What are the effects of poor maternal glycemic control during pregnancy?
``` 1st trimester - major birth defects - spontaneous abortions 2nd + 3rd trimester - hyperinsulinemia - macrosomia ```
243
Name congenital abnormalities of diabetic embryopathy in maternal type I diabetes
``` CNS - neural tube defects - holoprosencephaly Cardiac - hypertrophic interventricular septum - ASD - VSD - TGA - coarctation Renal - agenesis - dysplasia - hydronephrosis GIT - small left colon - bowel atresia - anorectal malformation Skeletal - caudal regression syndrome Facial - midline cleft - microsomia - microtia/anotia ```
244
Name delivery complications of infants to diabetic mothers
``` Shoulder dystocia Brachial plexus injury Humerus fracture Clavicle fracture Visceral trauma ```
245
Name postnatal complications of infants to diabetic mothers
Prem birth -> poor feeding Hyperinsulinism -> hypoglycemia Hyperinsulinism -> low cortisol -> decr surfactant -> RDS Macrosomia -> C/S -> transient tachypnoea of the newborn Polycythaemia -> stroke, renal vv thrombosis, seizures, jaundice Transient hypoparathyroidism -> hypocalcemia, hypomagnesemia Excess RBC precursors in bone marrow -> thrombocytopenia
246
Discuss the management of infants to diabetic mothers
Prevent hypoglycemia Identify complications Screen for congenital abnormalities
247
What is normal physiological weight loss after birth and when will it be regained?
7-10% | Regained by 10-14 days postdelivery
248
Name causes of poor feeding
``` Inadequate breastfeeding Hypoglycemia Infection Electrolyte abnormalities Inborn error of metabolism ```
249
What is a normoglycemia in a neonate?
≥ 2.6mmol/l on 2 occasions
250
Name risk factors for hypoglycemia in the neonate
SGA IUGR LGA IDM
251
What is a differential diagnosis of delayed passing of meconium in the neonate?
Imperforated anus Meconium ileus Intestinal atresia
252
What is a differential diagnosis for delayed passing of urine in the neonate?
Dehydration Posterior urethral valves Renal dysgenesis Renal agenesis
253
Name causes of apnoea attacks in the neonate
``` Seizure Hypoglycemia Sepsis IVH Airway obstruction Premature resp centre ```
254
Is it normal for neonates to become cyanosed around the mouth in the first few days of life?
``` Yes esp during feeds BUT must exclude - congenital CHD - polycythaemia - infection ```
255
Why do you need to manage nasal discharge in the neonate ASAP?
Obligatory nose breather | Use saline drops and suction!
256
Name causes of regurgitation in neonates
``` Excessive volume feeds Not burped Feeding horizontally Lying down immediately after feed Poor LES tone ```
257
Name causes of pallor in the neonate
Twin-to-twin transfusion Foetomaterno haemorrhage Abruptio placenta
258
How do you manage a neonatal conjunctivitis that is only sticky?
Clean with sterile water
259
How do you manage a neonatal conjunctivitis that appears on day 3-5?
Gonococcal infection | 3rd generation cephalosporin IVI if severe
260
How do you manage a neonatal conjunctivitis that appears on day 5 - 14?
Chlamydia infection | Oral erythromycin
261
What is the common cause of omphalitis?
Staph/strep infection
262
How do you treat an umbilical granuloma?
Silver nitrate sticks to the granuloma for 3 days
263
How do you differentiate fungal from contact dermatitis?
Contact - does not involve the skin folds | FUngal - red papules, involves skin folds, does not heal after conventional management
264
How do you prevent nappy dermatitis?
Change immediately after wet/soiled | Clean skin with warm water
265
How do you manage nappy dermatitis?
Keep skin dry and clean Leave bottom exposed to air Wash skin with warm water Use mild soap only to clean after stools If fungal - apply antifungal 4x day OR after each bottom cleaning for stools
266
Is oral thrush common in neonates or do you suspect something more?
Common in neonates | NOT indicative of secondary immunodeficiency
267
When do you administer VZIG to the newborn?
Mother develops vesicle 5 days before delivery - 2 days after delivery
268
How do you treat neonatal chicken pox?
IV acyclovir
269
What types of neonatal HSV are there?
Disseminated Encephalitis Localised
270
How do you treat neonatal HSV?
IV acyclovir
271
How do you treat SSS syndrome?
IV ABs
272
What is the cause of epidermolysis bullosa?
Genetic in areas of trauma/friction
273
How do you treat epidermolysis bullosa?
Prevent dehydration Prevent infection Analgesia
274
How do you differentiate jittery movements from a seizure in the newborn?
Jittery movements -> stop when holding limb | Seizure -> continues when holding limb
275
What is the gold standard of diagnosing seizure in newborn?
Video EEG
276
Name causes of seizures in the newborn
``` Hypoglycemia Electrolyte abnormality Meningitis Drug withdrawal Hypoxic brain injury IVH ICH ```
277
Discuss treatment of seizures in the newborn
Phenobarbitone Levetiracetam BZDs
278
Name symptoms and signs of neonatal hypoglycemia
``` Jittery Irritable High pitched cry Lethargy Decr LOC COma Hypotonia Apnoea Seizures ```
279
Name risk factors for neonatal hypoglycemia
Antenatal - maternal diabetes - maternal obesity - maternal beta blockers Neonatal - IUGR - prem - LGA - sepsis - iatrogenic (no feeds/fluids) - polycythaemia - HIE - hypothermia - rhesus disease
280
Name causes of persistent hypoglycemia in the neonate
``` Hyperinsulinism - IDM - BW sydrome - insulinoma Endocrine deficiency - panhypopituitarism - GH deficiency - adrenal deficiency Inborn error of metabolism ```
281
What investigations will you order in a neonate with persistent hypoglycemia?
``` Serum glucose Serum insulin Serum cortisol Serum GH Adrenal gland sonar Brain imaging IEM investigations ```
282
How do you manage neonatal hypoglycemia?
Early feeding to prevent Asx/glucose betw 1.4-2.5mmol/l = enteral feeds Sx/glucose <1.4mmol/l = IV 10% dextrose bolus followed by continuous infection Treat the underlying cause
283
What are the WHO recommendations for optimal infant feeding?
1. Exclusive breastfeeding for 6months -> complementary feeding from 6 months up to 2yo
284
What are exceptions that are allowed in exclusive breastfeeding?
Oral rehydration solution Vitamin/minerals Medication
285
Give reasons for exclusively breastfeeding for 6 months
1. Provides all nutritional needs 2. Benefits increase with duration 3. Risk of death from diarrhoea reduced 4. Risk of resp illness reduced 5. PMTCT
286
What does breastmilk contain?
``` Water Fat Carbohdydrates Vitamins Minerals Oligosaccharides Whey proteins WBC Immunoglobulins Epidermal GFs ```
287
What is the role of whey proteins in breastmilk?
Kills bacteria, viruses and fungi
288
What are the benefits of breastfeeding for the mother?
``` Short term Decr risk of PPH Accelerate prepregnancy weight recovery Bonding Free, convenient and readily available ``` Long term Delays return of fertility Decr breast and ovarian Ca risk Decr risk of DM II, HT, CV disease and hyperlipidemia
289
What are the benefits of breastfeeding for the infant?
``` Short term Ideal nutrition Healthy weight gain Easily digested -> less constipation Maintain GIT integrity Infection protection Decr SIDS risk ``` ``` Long term Decr immunological diseses Better cognitive function Decr obesity Decr adulthood CV risk Decr childhood leukemia risk ```
290
Name infant conditions where breastmilk substitutes are required
Galactosemia Maple syrup urine disease Phenylketonuria Hypoglycemia
291
Name maternal conditions where breastmilk substitutes are required
``` Severe illness Medication Substance abuse HIV infection w/ high viral load on 2nd line ART Hepatitis C ```
292
What medications contraindicate breastfeeding?
Radioactive iodine Cytotoxic chemotherapy Sedatives
293
How many calories does a preterm infant require and what is the target feed volume?
120-150kcal/kg/day | 160-180ml/kg/day
294
How many calories does a term infant require and what is the target feed volume?
100kcal/kg/day | 150ml/kg/day
295
Name an example of breastmilk fortifier
FM85
296
What is the name of the multivitamin given to preterm infants?
Vidaylin
297
Why is phosphate supplementation necessary in the preterm infant?
Need large amount of phosphate to grow -> don't have -> osteopenia -> metabolic bone disease of prematurity
298
What factors promote lactation?
Frequent feeding Empty breasts Calm environment Medication (metaclopromide, sulpiride)
299
What factors inhibit lactation?
Breasts engorged Stressful environment Pain, illness Medication (oestrogen, bromocriptine)
300
When is prolactin production highest?
At night
301
Give examples of breastfeeding positions
``` Cradle Cross cradle Back lying Football Australian hold Inverted side lying Side lying cradle Side lying ```
302
Give signs of adequate milk intake
Good weight gain Good urine output Change from meconium to transitional stools by day 4
303
Name causes of inadequate milk intake
``` Delayed initiation of breastfeeding Poor attachment Infrequent/short feeds Bottle/dummy use Giving other liquids/soft foods Not feeding at night ```
304
How should HIV mothers breastfeed when experiencing breast pain?
Should only feed using the unaffected breast | If both breasts - consider pasteurizing if no alternative feeding available
305
Name signs of breast candida infection
``` Mother - sore nipples - red/flaky rash on areola Infant - oral thrush - may refuse feeds ```
306
How do you treat a breast candida infection?
Nystatin suspension QID x7d after breastfeeds | Nystatin cream QID x7d after breastfeeds
307
Explain the process of bilirubin synthesis
Hemolysis of RBC -> heme + globin Free heme binds to haptoglobin -> low s haptoglobin Heme is oxidated via heme oxygenase -> biliverdin Biliverdin catalysed by biliverdin reductase -> bilirubin UC, fat soluble bilirubin binds to albumin -> transported to liver -> dissociates with albumin to enter liver UCB binds to intracellular proteins -> transported to endoplasmic reticulum -> conjugated to glucoronic acid via UGT -> water soluble Water soluble CB -> excreted into bile caniculus -> intestine -> hydrolysed via beta glucoronidase to UCB -> goes back to liver
308
What happens to the bilirubin excreted into the intestine?
25% reabsorbed as UCB 10% excreted unchanged as CB 65% -> urobilinoids -> stercobilinogen (majority) + urobilinogen
309
What colour is urobilinogen?
Colourless!
310
Categorise the causes of unconjugated jaundice
Increased production Decreased hepatic uptake/conjugation Increased enterohepatic circulation
311
Categorise the causes of conjugated jaundice
Hepatocellular dysfunction | Biliary obstruction
312
What is the cause of physiological jaundice
High hb due to hypoxic environment no longer needed and RBC lifespan shorter -> increased RBC breakdown -> intravascular haemolysis
313
Name intravascular causes of haemolysis in the neonate
``` Physiological Allo-immune - ABO incompatibility - Rh incompatibility - minor antigen incompatibilities Non-immune - RBC membrane defects - RBC Hb defects - RBC enzyme defects ```
314
Name extravascular causes of haemolysis in the neonate
Cephalhaematoma Bruising Subaponeurotic bleed IVH
315
How do we establish whether the haemolysis is allo-immune or non-immune?
Direct Coombs test
316
What is Coombs reagent?
Antihuman antibodies
317
How does a Coombs test test positive?
Foetal blood with maternal antibodies (Rh, ABO) + Coombs reagent -> agglutination -> positive
318
Which blood group has IgG antibodies?
O
319
Why does ABO incompatibility not occur in AB babies?
Mother has to be O blood group -> cannot have an AB baby
320
Why does ABO incompatibility not occur in A,B or AB mothers?
The antibodies are IgM
321
Name RBC membrane defects in the neonate
Hereditary spherocytosis | Hereditary elliptocytosis
322
Name RBC haemoglobin defects in the neonate
A-thalassemia
323
Name RBC enzyme defects in the neonate
Glucose-6-phosphate dehydrogenate deficiency | Pyruvate kinase deficiency
324
How can you diagnose an RBC membrane defect?
Assess the osmotic fragility of the RBC
325
Why do newborns not present with beta thalassemia or sickle cell disease?
Newborns have haemoglobin f not haemoglobin a
326
What investigations should you do to diagnose intravascular haemolysis and what results do you expect?
``` Hb -> decreasing/low Reticulocytes -> high LDH -> high Haptoglobin -> low RBC fragments on smear ```
327
Name causes of decreased hepatic uptake and conjugation in the neonate
Physiological: Decreased net hepatic uptake Immature liver enzymes ``` Pathological: Breast milk jaundice Hypothyroidism Gilbert's disease Crigler-Najjar syndrome ```
328
Name causes of increased enterohepatic circulation in the neonate
Breastfeeding jaundice Meconium ileus Hirschprung disease Intestinal atresia
329
Why is breastfeeding jaundice a misnomer?
They are NOT feeding well -> poor intake -> delayed stool passage -> incr enterohepatic circulation
330
What investigations are required in unconjugated neonatal jaundice?
TSB Direct bilirubin If indirect bilirubin high - Hb - reticulocyte - LDH - haptoglobin - RBC smear If intravascular haemolysis - direct Coombs test + Coombs - ABO - Rh - Coombs - RBC membrane defects - RBC Hb defects - RBC enzyme defects
331
What does a biliruin rising >17umol/l/hr indicate?
Severe haemolysis -> pathological jaundice
332
Compare the difference between Rh and ABO incomptaibility
``` Rh: Mom Rh - Dad Rh + Baby Rh + Sensitization yes ``` ``` ABO: Mom O Dad A,B or AB Baby A or B Sensitization no ```
333
Discuss the management of unconjugated jaundice
Phototherapy Exchange transfusion IVIG
334
Name dangers of unconjugated jaundice?
Bilirubin neurotoxicity
335
How can bilirubin neurotoxicity occur?
UCB -> water soluble -> crosses BBB | CB -> BBB disrupted -> crosses BBB
336
Name signs of acute bilirubin encephalopathy
Early - hypotonia - lethargy - poor suck - high pitched cry Intermediate - irritability - fever - convulsions - w/wo opisthotonus Advanced - severe opisthotonus - apnoea - convulsions - coma - death
337
Name signs of chronic bilirubin encephalopathy
``` Athetosis Sensorineural deafness Dental dysplasia Teeth discolouration Intellectual deficits ```
338
What would MRI of the brain show in chronic bilirubin encephalopathy?
Increased signal intensity - basal ganglia - cranial nn nuclei - cerebellar nuclei
339
What would autopsy of the brain show in chronic bilirubin encephalopathy?
Kernicterus
340
Name indications for phototherapy
``` Absolute - phototherapy chart Prophylactic - ELBW - extravascular blood collections ```
341
What is a contraindication for phototherapy?
Conjugated jaundice -> bronze baby syndrome (iireversible!)
342
Explain how phototherapy works
Uses blue green light to convert UCB into water soluble isomers Structural isomers excreted into bile + urine Configurational isomers excreted into bile
343
What should the blue light spectrum be in phototherapy?
425-475nm
344
What should the irradiance be in phototherapy?
10-30uW/cm2/nm
345
How far should the light be from the infant?
20cm
346
Give examples of types of phototherapy lights
Fluorescent tubes LED lights Halogen bulbs
347
Name complications of phototherapy
``` Impaired bonding Incr water loss Watery stools Maculopapular skin rash Lethargy Potential for retinal damage ```
348
What do you do using the phototherapy chart if the time is after 120h?
Plateus at 120h -> use the threshold measurement
349
Name indications for exchange transfusion
1. TSB >85umol/L above threshold at presentation 2. TSB remains above EL despite 6hrs of intensive phototherapy 3. Any signs of acute bilirubin encephalopathy 4. TSB rising >17umol/l/hr despite intensive phototherapy
350
Why do we perform exchange transfusion when TSB>85umol/L
We do not expect the TSB to fall below the threshold within 6hours
351
How does exchange transfusion aid in elevated bilirubin?
Removes maternal antibodies Replaces 87% of blood with new blood Removes bilirubin from plasma
352
What blood is used for exchange transfusion?
Fresh, irradiated, reconstituted whole blood from packed RBC and FFP Contains no platelets
353
How do you perform an exchange transfusion?
``` Use umbilical venous catheter Exchange double the BV - term 160ml/kg - preterm 180mk/g Aliquots of 5ml/kg max 20ml every 2min ```
354
Name complications of exchange transfusions
``` Hypocalcemia Hypoglycemia Hyperkalemia Vasospasm Arrythmias Bleeding Infections Graft-vs-host disease Hypothermia Volume overload ```
355
Why does hypocalcemia occur in exchange transfusion?
Citrate in the blood bag to prevent clotting
356
Why does hypoglycemia occur in exchange transfusion?
RBC use glucose | Usually feeds stopped during transfusion
357
Why does hyperkalemia occur in exchange transfusion?
RBC lyse due to mechanical stressors
358
Why do vasospasms occur in exchange transfusion?
Catheter related
359
Why do arrythmias occur in exchange transfusion?
Catheter related
360
Why does bleeding occur in exchange transfusions?
Low platelets
361
Why do infections occur in exchange transfusion?
Blood not properly screened
362
Why does graft-vs-host disease occur in exchange transfusion?
Immune reaction if blood not irradiated
363
Why does hypothermia occur in exchange transfusion?
Blood not warmed prior to use
364
Why does volume overload occur in exchange transfusion?
More blood transfused than removed
365
Explain how IVIG works to reduce the rate of haemolysis in infants with alloimmune haemolysis
Binds to RE receptors and blocks them -> RE cell unable to bind to antibody on RBC -> RBC does not lyse
366
What is conjugated jaundice also known as?
Cholestatic jaundice
367
When do you diagnose conjugated hyperbilirubinaemia?
CB > 20% TSB
368
What colour is conjugated bilirubin in the urine?
Dark urine
369
What lab investigations indicate hepatocellular dysfunction?
Incr AST/ALT
370
Name causes of hepatocellular dysfunction in neonates
Infections: - TORCHES - HIV - parvovirus B19 - UTI - sepsis Metabolic/genetic: - galactosemia - tyrosenemia - Niemann Pick disease type C - alpha 1 antitrypsin deficiency - Gauchers - CF Endocrine: - hypothyroidism - hypopituitarism Allo-immune: - gestational alloimmune liver disease (GALD) Toxins: - drugs eg INH - parenteral nutrition Misc: - idiopathic neonatal hepatitis
371
What lab investigations indicate biliary obstruction?
Incr ALP/GGT
372
Name causes of biliary obstruction
Extrahepatic: - biliary atresia - choledocal cyst - choledocal stones - tumour/mass - neonatal sclerosing cholangitis - inspissated bile syndrome Intrahepatic: - alagille syndrome - intrahepatic biliary atresia
373
Name complications of jaundice found on examination
1. Encephalopathy - raised ammonia (LF) - hypoglycemia (LF) 2. Cataracts - metabolic disease - congenital infection 3. FTT - advanced liver disease - sepsis - metabolic disease 4. Bleeding - coagulopathy (LF) 5. Firm hepatomegaly - biliary atresia 6. Splenomegaly - storage disease 7. Portal hypertension - HSM - ascites - caput medusa 8. Acholic stool/dark urine - obstructive jaundice
374
Discuss management of conjugated jaundice
``` Give ADEK vitamins MCT oil Adequate calories Ursodeoxycholic acid Avoid lactose in galactosemia Surgical ```
375
Why do we give ursodeoxycholic acid?
Promotes bile excretion
376
What investigations are required in conjugated neonatal jaundice?
TSB and direct bilirubin Direct >20% TSB = conjugated Test liver enzymes Raised ALP/GGT = obstructive = abdominal U/S + urine dipstix Raised AST/ALT = hepatocellular = multiple investigations Last resort -> liver biopsy
377
What investigations should you do for hepatocellular causes of conjugated hyperbilirubinaemia?
``` Infections GALT A1AT Thyroid function Serum ferritin Sweat test Fecal elastase ```
378
Which investigations are used to assess liver function?
``` INR PTT Albumin Ammonia Glucose ```
379
When can NVP be stopped in the infant during PMTCT and under what condition?
Stop at 12 weeks if mother's VL <1000c/ml
380
What do we give as low risk PMTCT prophylaxis?
NVP daily x 6w
381
What do we give as high risk PMTCT prophylaxis?
Breastfeeding: NVP 12w and AZT 6w | Formula fed: NVP 6w and AZT 6w
382
What do you put the infant on in PMTCT after stopping the ARVs and when do you stop this medication?
Cotrimoxazole Stop when - PCR - >6w after breastfeeding cessation AND - infant clinically HIV negative
383
What is the prophylactic dose of zidovudine according to weight?
``` <2kg = 4mg/kg/dose 2.0 - 2.49kg = 10mg 2.5 - 2.99kg = 15mg 3.0-5.9kg = 60mg 6 - 7.9kg = 90mg 8-13.9kg = 120mg ```
384
What is the prophylactic dose of nevirapine according to weight
``` 2.0-2.49kg =10mg >2.5kg = 15mg >6w - 6m =20mg 6-9m = 30mg >9m = 40mg ```
385
What is the prophylactic dose of cotrimoxazole syrup according to weight
2.5-5kg = 2.5ml | 5 - 13.9kg = 5ml
386
Which infants are at higher risk of developing anemia on AZT?
Premature | Malnourished
387
When do we test the infant in PMTCT?
``` Birth PCR 10w PCR 6m PCR (HIV exposed) 18m RAPID/ELISA for ALL children 6w postcessation of BF Any time symptomatic ```
388
How common is cleft lip/palate?
1/1000 live births
389
What is the cause of cleft lip/palate?
In the 8th week of gestation, failure of fusion of medial and lateral nasal processes (lip) and maxillary processes (palate)
390
Discuss management of cleft lip/palate
Surgical repair of lip at 3 months | Surgical repair of palate at 6-12m
391
Name complications of cleft lip/palate
``` Short term - feeding difficulties Long term - OME - hearing impairment - speech difficulties - facial growth issues - orthodontic issues ```
392
How can you assist with feeding difficulties in cleft lip/palate?
Special teats | Dental plate
393
What is Pierre Robin sequence?
Autosomal recessive Mandibular hypoplasia between 7th and 11th week of gestation -> tongue high in oral cavity -> inverted U shaped cleft Triad: 1. Micrognathia 2. Retroglossoptosis 3. Posterior palatal defect
394
Name complications of Pierre Robin sequence
Resp obstruction Hypoxia Pulmonary hypertension Cor pulmonale
395
What other genetic form of Pierre Robin sequence has been reported?
X linked variant assoc with cardiac malformations and club feet
396
Discuss management of Pierre Robin sequence
Avoid tongue obstruction - nurse prone - CPAP vs NPT Surgical repair of posterior palate at 1yo
397
Discuss management of choanal atresia
Oral airway/intubate | Surgical correction asap
398
Name causes of respiratory distress in newborns
``` Birth asphyxia Sepsis Transient tachypnoea of the newborn Meconium aspiration syndrome Respiratory distress syndrome Congenital diaphragmatic hernia Pneumonia Pneumothorax ```
399
Explain the mechanism of transient tachypnoea of the newborn
Lower [ ] of circulating catecholamines -> reduced reabsorption of alveolar fluid via sodium channels in the lung epithelium -> TTN
400
When is TTN most common?
C/S
401
Discuss management of TTN
Oxygen Nasogastric feeding CPAP
402
Name constituents of meconium
Intestinal epithelial cells Lanugo Mucus Intestinal secretions (bile)
403
Why does meconium aspiration mainly affect infants born at term and post term?
Meconium is rarely found in amniotic fluid <34-36w GA
404
Name causes of meconium aspiration
``` Any cause of intrauterine stress Placental insufficiency Hypoxia Maternal hypertension Preeclampsia Oligohydramnios Maternal drug abuse ```
405
Name complications of meconium aspiration
``` Airway obstruction Surfactant dysfunction Chemical pneumonitis Pneumothorax PPHN ```
406
Discuss management of meconium aspiration
``` Mechanical ventilation Systemic vasoconstrictors (inotropes) Sildenafil Nitric oxide NO CPAP ```
407
Name risk factors for congenital pneumonia
``` PROM Maternal fever Maternal tachycardia Chorioamnionitis Maternal UTI Maternal avginitis Spontaneous preterm labour ```
408
What is the most common cause of congenital pneumonia?
GBS
409
Discuss treatment of congenital pneumonia
Penicillin | Ventilation
410
How should all infants with respiratory distress be managed?
Start on broad spectrum ABs until results known - blood culture - CRP - FBC - lumbar puncture
411
What is a Bochdalek diaphragmatic hernia?
Hernia of bowel through the posterolateral foramen of the diaphragm
412
What is a Morgagni diaphragmatic hernia?
Hernia of bowel through central anterior of diaphragm
413
Name signs of diaphragmatic hernia
Resp distress Chest assymetry Apex beat displaced Scaphoid abdomen
414
Discuss management of a congenital diaphragmatic hernia
``` Intubate and ventilate from birth Pass NGT and suction Stabilise Early PN Nitric oxide/sildenafil for PPHN Surgical repair NO CPAP ```
415
Describe the ventilation required in the management of a congenital diaphragmatic hernia
Gentle ventilation, allowing permissive hypercapnia, i.e. PaCO2 > 60 mmHg (8kPa) but maintaining pH >7.25
416
Name signs of pneumothorax
Chest assymetry Unilateral decr breath sounds Unilateral decr chest movements Transillumination of chest
417
What are the complications of oxygen therapy in the infant
``` Retinopathy of prematurity NEC IVH Bronchopulmonary dysplasia Chronic lung disease ```
418
Discuss management of PPHN
``` Oxygen Mechanical ventilation Surfactant therapy Pulmonary vasodilator High frequency oscillatory ventilation ECMO ```
419
Categorise sepsis and differentiate between these categories
``` Early onset sepsis - transplacental or genital tract - 48-72hrs Late onset sepsis - nosocomial, community and environment - >72hrs ```
420
Name examples of organisms involved in early onset sepsis
GBS Gram - Listeria Staph aureus
421
Name examples of organisms involved in late onset sepsis
``` GBS Gram - Staph aureus CoNS Enterococcus Fungal ```
422
Define neonatal sepsis
Presence of infections involving bloodstream, urine, cerebrospinal, peritoneal structures and/or sterile tissues during first 28 days of life
423
The earlier the presentation of sepsis post delivery, the ____ the clinical presentation and outcome?
Worse
424
What is the most common source of postnatal infections in infants admitted in hospitals?
Hand contamination
425
Name maternal risk factors for early onset neonatal sepsis
``` Premature labour PROM>18hrs Traumatic delivery Chorioamnionitis Maternal fever >38 MSL Low SES GBS bacteruria ```
426
Name neonatal risk factors for early onset neonatal sepsis
``` Prematurity Male Low apgar Hypothermia Foetal distress ```
427
Name neonatal risk factors for late onset neonatal sepsis
``` GA:weight inverted Central catheters Ventilation ABs PN Gastric acid suppression therapy Skin damage (tape, probe) ```
428
Name clinical signs and symptoms of infection in the neonate
Skin - omphalitis - petechiae - poor circulation - jaundice GIT - intolerance - vomiting - diarrhoea - abdominal distension - jaundice Cardiopulmonary - resp distress - poor capillary refill - tachy/bradycardia Metabolic - hypoglycemia - hyperglycemia - metabolic aidosis
429
What is the gold standard for diagnosing neonatal infection?
Blood/urine/CSF culture using strict aseptic technique
430
What should CSF be sent for?
Chemistry Microscopy Culture Latex agglutination
431
What are signs of NEC on AXR?
Dilated loops of bowel Pneumatosis intestinalis No air in rectum
432
What I/T ratio suggests infection?
>0.2
433
Why is there a delayed rise in CRP for newborns?
Time needed for release by liver in response to IL6
434
What is initial empiric treatment for early onset sepsis?
Pen G Ampicillin Amikacin
435
What is initial empiric treatment for late onset sepsis?
Cephallosporins Vancomycin Carbapenems Antifungals
436
Which drugs are reserved for gram - meningitis?
3rd/4th gen cephalosporin
437
What is specific anti-RSV prophylaxis?
Palivizumab
438
Name viruses that cause congenital infections
``` CMV Rubella HSV VZV PB19 HBV HCV HIV Enterovirus HPV ```
439
Name bacteria that cause congenital infections
Toxoplasma gondii Treponema pallidum Mycobacterium tuberculosis Plasmodium
440
Differentiate between a primary and secondary maternal infection
Primary - acquired in pregnancy + most likely to cause disease Secondary - reactivation of prev infection + less likely to cause disease
441
Name clinical signs of CMV
``` Prematurity Rash IUGR Jaundice HSM Microcephaly Seizures Hypotonia Lethargy Chorioretinitis Intracranial calcifications Sensorineural hearing loss ```
442
How do you diagnose CMV?
Mother - IgG - IgM - CMV DNA PCR Infant - IgM - CMV viral DNA
443
How do you treat congenital CMV?
Oral valganciclovir for 6 months | IV ganciclovir for 6w at 6mg/kg/dose
444
How do infants with congenital rubella infection present?
Petechiae Jaundice HSM
445
What kind of virus is rubella?
Ss + sense RNA virus
446
How do you diagnose congenital rubella?
DNA PCR <1yo IgM <3mo IgG 6-12mo
447
Name sources of toxoplasmosis infection
``` Undercooked meat/meat products Raw fruits Raw vegetables Poor hygiene Contaminated surface water Cat faeces ```
448
When is the risk of toxoplasmosis infection transmission from the mother to the child highest?
3rd trimester
449
When is the risk of toxoplasmosis infection causing harm to the baby highest?
1st-2nd trimester
450
What is the classic tetrad of toxoplasmosis?
Hydrocephalus Epilepsy Cerebral calcification Chorioretinitis
451
Discuss treatment of neonatal varicella
Immunoglobulin | Acyclovir
452
Discuss immunoprophylaxis of hepatitis B
Single antigen HBV cavvine | HBIG 0.5ml
453
Discuss the stages of syphilis in the mother
1. 3-6w: painless, spontaneously resolving paple 2. 6-8w: diffuse inflammation and disseminated rash 3. Latent stage 4. Granulomas affecting bones, joints, CV and neurological systems
454
Name the clinical manifestations of early congenital syphilis
``` Prem Growth restriction HSM Nasal chondritis Skin rash Osteochondritis Hydrocephalus ```
455
Name the clinical manifestations of late congenital syphilis
``` Craniofacial abnormalities Dental abnormalities Interstitial keratitis Deafness Neurosyphilis ```
456
What investigations would you do in a case where you suspect congenital syphilis?
``` Dark field microscopy of placenta VDRL RPR Enzyme immunoassay FTA-ABS ```
457
Discuss the treatment of congenital syphilis
IV penicillin
458
What is the new FDC?
Tenofovir (TDF) Lamivudine (3TC) Dolutegravir (TLD)
459
What anomaly is dolutegravir use associated with?
Neural tube defects | Avoid in periconception and first 6w of pregnancy
460
Define VL suppression in HIV
VL <50c/ml
461
Classify prematurity
``` <37w Late preterm = 34-36w6d Moderate preterm = 32-34w Very preterm = 28-32w Extreme preterm = <28w ```
462
Classify low birth weight
<2500g LBW = 1500-2499g VLWB = 1000-1499g ELBW = <1000g
463
Give benefits of delayed cord clamping
``` Improves BP Reduces IVH Reduces NEC Reduces need for vasopresssors Reduces need for blood transfusion ```

Coovadias Paediatrics (10 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions