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Yr4 - Paeds > Neonatology > Flashcards

Neonatology Flashcards

1
Q

Define neonate

A

From birth to 28 days of age

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2
Q

Admission to neonates

A

Birth - labour ward
PNW - postnatal week
Home - exchange transfer
Transfer from another hospital

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3
Q

Define early onset neonatal sepsis (EONS)

A

Sepsis occuring within the first 48-72 hours of life

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4
Q

Common PC for neonates

A 
Prematurity
Respiratory distress - grunting
Cyanosis
Jaundice
Poor feeding
Weight loss
Know congenital abnormalities
Fractures/skull swelling
Concerns about sepsis
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5
Q

Causes of EONS

A

Chorioamnionitis perinatally via direct contact in the birth canal and haematogenous spread

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6
Q

Main organism of EONS

A 
Group B streptococcus
- most common
- gram-positive coccus
- present in 25% of pregnant women's genital tract - infection via direct contact
E-coli
Coagulase-negative straphylococcus
H influenzae
Listeria monocytogenes
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7
Q

Risk factors for EONS

A

Invasive group B strep infection in previous baby
Maternal group B strep colonisation, bacteruria or infection in current pregnancy
Prelabour rupture of membranes
Preterm birth following spontaneous labour
Suspected or confirmed rupture of membranes for more than 18 hours in a preterm birth
Intrapartum fever higher than 38
Parental antibiotic treatment for invasive bacterial infection at anytime during labour - red flag
Suspected or confirmed infection in another baby in the case of multiple pregnancy - red flag

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8
Q

Clinical indicators suggestive of infection

A

Altered behaviour or responsiveness
Altered muscle tone (for example, floppiness)
Feeding difficulties (for example, feed refusal)
Feed intolerance, including vomiting, excessive gastric aspirates and abdominal distension
Abnormal heart rate (bradycardia or tachycardia)
Signs of respiratory distress
Respiratory distress starting more than 4 hours after birth (Red Flag)
Hypoxia (for example, central cyanosis or reduced oxygen saturation level)
Jaundice within 24 hours of birth
Apnoea
Signs of neonatal encephalopathy
Seizures (Red Flag)
Need for cardio–pulmonary resuscitation
Need for mechanical ventilation in a preterm baby
Need for mechanical ventilation in a term baby (Red Flag)
Persistent fetal circulation (persistent pulmonary hypertension)
Temperature abnormality (lower than 36°C or higher than 38°C) unexplained by environmental factors
Signs of shock (Red Flag)
Unexplained excessive bleeding, thrombocytopenia, or abnormal coagulation (International Normalised Ratio greater than 2.0)
Oliguria persisting beyond 24 hours after birth
Altered glucose homeostasis (hypoglycaemia or hyperglycaemia)
Metabolic acidosis (base deficit of 10 mmol/litre or greater)
Local signs of infection (for example, affecting the skin or eye

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9
Q

Red flag signs for suggestive neonatal infection

A

Systemic antibiotics given to mother for suspected bacterial infection within 24hr of birth
Seizures
Signs of shock
Resp distress starting more than 4 hours after birth
Need for mechanical ventilation in term baby
Suspected or confirmed infection in co-twin

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10
Q

Differential diagnosis for EONS

A

Transient Tachypnoea of the newborn (TTN) - in term babies, causes tachypnoea and increased work of breathing
Surfactant deficient lung disease / respiratory distress syndrome (RDS) - especially in preterm infants can cause tachypnoea and increased work of breathing
Meconium Aspiration - can cause the baby to be born in poor condition, with respiratory distress, and may require intubation. Meconium aspiration can cause a rise in CRP.
Haemolytic Disease of the Newborn - can present with jaundice within the first 24 hours of life.

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11
Q

Investigations for EONS

A 
FBC
CRP
Blood cultures
Relevant swabs/cultures
LP - if suggestive of meningitis
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12
Q

Management of EONS

A

IV benzylpenicillin with gentamicin

  • if cultures + then continue for 7-10 days
  • up to 14 days if CSF also +
  • raised CRP but - cultures 5 days
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13
Q

Define jaundice

A

Yellow colouring of skin and sclera caused by the accumulation of bilirubin

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14
Q

Epidemiology of neonatal jaundice

A

60% of term infants

80% of preterm infants

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15
Q

Physiological causes of jaundice

A

Physiological - jaundice in a healthy baby born at term is normal
Starts at day 2-3, peaks at day 5 and resolved by day 10
- increased RBC breakdown-
- immature liver

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16
Q

Pathological causes of jaundice

A

Onset less than 24 hours = Haemolytic disease
- haemolytic disease of the newborn (rhesus)
- ABO incompatibility
- GPD deficiency
- spherocytosis
Onset after 24 hours
- likely dehydrated
- increased haemolysis due to bruising/cephalohematoma
Unwell neonate = congenital or post-natal infection
Prolonged jaundice - > 14 days in term and 21 days in preterm
- infection
- metabolic - hypothyroid/pituitarism, galactosaemia
- breast milk jaundice - well baby, resolves between 1.5-4 months
- GI - biliary atresia, choledhocal cyst

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17
Q

Define preterm birth

A

Delivery before 37 weeks

  • extreme = before 28 weeks
  • very = 28-32 weeks
  • moderate to late = 32 to 37 weeks
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18
Q

Epidemiology of preterm birth

A

15 million babies born premature each year
- 60,000 in UK
Number one cause of neonatal death globally
number 1 cause of death for under 5s

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19
Q

Risk factors for premature birth

A

Previous preterm delivery
Multiple pregnancy
Smoking and illicit drug use in pregnancy
Being under or overweight in pregnancy
Early pregnancy - within 6 months of previous pregnancy
Problems involving cervix, uterus or placenta - including infection
Certain chronic conditions such as diabetes and hypertension
Physical injury/trauma

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20
Q

Investigations for premature birth

A

Blood gas - assess resp and metabolic state of infant
FBC - high risk of infection, thrombocytopenia and anaemia
U+Es and creatinine - electrolyte and fluid balance
Blood culture
CRP
Blood group and Direct Coombs Test/Direct Antiglobulin Test - blood transfusion and jaundice
CXR - if showing signs of resp distress
AbdoX - central venous and arterial access inserted through umbilical vein and arteries
Cranial USS - assess for signs of haemorrhagic, ischaemic and infective factors

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21
Q

Initial management of preterm birth

A

Planned delivery in hospital with in tertiary level neonatal hospital
Antenatal steroids
Magnesium sulphate - neuroprotective

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22
Q

Guidelines around resuscitation of extreme pre-term infants

A

Less than 23 weeks - resuscitation not performed
23-23+6 weeks - decision not to start resuscitation in best interests of baby especially if parents agree
24 and 24+6 weeks - resuscitation commenced unless baby thought to be severely compromised
After 25 weeks - appropriate to resuscitate and start intensive care

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23
Q

Features of intraventricular haemorrhage

A

Parenchymal bleed due to immature BBB
Bleed during birth due to increased maternal and baby BP
Leads to cerebral palsy - managed by early physiotherapy

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24
Q

Features of surfactant deficiency

A

Difficulty breathing
Cyanosis
Intercostal recession
Increased RR, HR and reduced SaO2

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25
Formation of lungs
``` Type 1 pneumocytes - needed for gas exchange - form at 32 wks Type 2 pneumocytes - produce surfactant - form at 24 weeks ```
26
Investigations for infant respiratory distress
Blood gas - usually type 1 resp failure = low O2 and high CO2 CXR - acute respiratory distress syndrome - cloudy, speckly = ground-glass sign
27
Differential diagnosis of respiratory distress in a newborn
Surfactant deficiency Infection Pneumonia
28
Management of surfactant deficiency
Antenatal steroids if signs of premature labour Artificial surfactant - 1 per 12 hours Long term = ventilation
29
Complications of long term ventilation of newborns
Bronchopulmonary dysplasia - fibrosis of lung - damage due to barotrauma Most common in those ventilated from 32-36 weeks + Increased risk of asthma and chest infections
30
Features of a patent ductus arteriosus
Machinery murmur - loudest at upper left chest Breathlessness Poor exercise tolerance Rapid HR
31
Define patent ductus arteriosus
Unclosed hole in the aorta | - oxygenated blood travels from aorta into pulmonary artery
32
Management of PDA
Ibuprofen - anti-prostaglandin effect | Surgical ligation if unsuccessful
33
Define NEC
Nectrosting Encephalitis | - overgrowth of gut bacteria -> infection
34
Features of NEC
``` Vomiting + diarrhoea Feeding intolerance Abdo distention Blood in stools Tachycardia ```
35
Ix for NEC
Abdo x-ray | - pneumatosis intestinalis = train track sign
36
Mx for NEC
Nil by mouth IV abx Total parenteral nutrition Surgical mx for perforated intestine - removal of affected section
37
Neurodevelopmental outcomes of premature babies
More premature = higher likelihood of neurodevelopmental impairment - infants born at 22 weeks, around 1/3 will have no or mild disability - increases to 75% at 26 weeks
38
Risk factors for neonatal jaundice
``` Prematurity, low birth weight or small for dates Previous siblings requiring phototherapy Exclusively breast fed Jaundice < 24 hours Infant of diabetic mother ```
39
Clinical presentation of neonatal jaundice
Colour - sclera, gums and blanche the ski Drowsy - difficult to rouse, not waking for feeds Neurology - altered muscle tone Other - signs of infection, poor urine output, abdo mass/organomegaly, stool remains black
40
Ix for neonatal jaundice
Transcutaneous bilirubinometer - >35/40 gestation and > 24hrs for 1st measurement Serum bilirubin - if <35/40 gestation, < 24hrs old or TCB > 250 micromol/L Only if appear jaundiced to naked eye
41
Mx for neonatal jaundice
Interpret bilirubin using treatment threshold graphs - gestation specific - the more premature infant the lower level of bilirubin tolerated before neurological impairment If above live initiated phototherapy and monitor bilirubin Do not give additional fluids unless indicated Exchange transfusion - prevent further bilirubin increase - via umbilical artery or vein IV Immunoglobulin - adjunct to phototherapy in rhesus haemolytic disease of ABO haemolytic disease
42
Complications of neonatal jaundice
Kernicterus - bilirubin-induced brain dysfunction - irreversible neurological damage to to high bilirubin
43
Define meconium aspiration syndrome
Spectrum of disorders marked by various degrees of respiratory distress in the newborn infant - follows the aspiration of meconium stained amniotic fluid either antenatally or during birth
44
Pathophysiology of meconium aspiration syndrome
Meconium stained amniotic fluid (MSAF) caused by in-utero peristalsis - result of foetal hypoxic stress or vagal stimulation due to cord compression Once aspirated can stimulate the release of vasoactive and cytokine substances - activate inflammatory pathways - inhibits effect of surfactant
45
Common features of MAS-related respiratory distress of the newborn
Partial or total airway obstruction - due to thick sticky consistency of meconium -> atelectasis and ball-valve effect with air trapping Foetal hypoxia - due to V/Q mismatch, increase of pulmonary vasculature, mechanical obstruction, airway oedema or surfactant inactivation Pulmonary inflammation - release of pro-inflammatory cytokines - tumour necrosis factor and interleukins - contribute to lung tissue, injury, surfactant inactivation and infection Infection - inflammation process predisposes lung to increased risk of infection and chemical pneumonitis Surfactant inactivation - increases surface tension of alveoli - reduces efficiency of gas exchange and exacerbates foetal hypoxia Persistent Pulmonary Hypertension - due to remodelling of pulmonary vasculature in response to hypoxia, vasoactive mediators and V/A mismatch
46
Risk factors for MAS
Gestational Age > 42 weeks Foetal distress - tachycardia / bradycardia Intrapartum hypoxia secondary to placental insufficiency Thick meconium particles Apgar Score <7 Chorioamnionitis +/- prolonged pre-rupture Oligohydramnios In utero growth restriction Maternal hypertension, diabetes, pre-eclampsia or eclampsia, smoking and drug abuse
47
Investigations for MAS
``` Diagnosis of exclusion CXR - increased lung volumes - asymmetrical patchy pulmonary opacities - pleural effusions - pneumothorax or pneumomediastinum - multifocal consolidation - due to chemical pneumonitis Infection markers - FBC - CRP - blood cultures ```
48
Ddx of MAS
``` Transient tachypnoea of the newborn - usually resolves in 24hrs without intervention - no hypoxia or cyanosis Surfactant deficiency - causes resp distress - more commonly seen in pre-term infants - no MSAF at delivery Persistent pulmonary hypertension - PDA ```
49
Management of MAS
``` Observation Routine care - infant warmer - continuous O2 sats - nutritional support - IV fluids Ventilation/O2 therapy - nasal cannula - CPAP - intubation and mechanical ventilation Antibiotics - if clinical suspicion of infection - stopped if negative blood cultures return Surfactant Inhaled Nitric Oxide - pulmonary hypertension Corticosteroids ```
50
Complications of MAS
``` Air leak - pneumothorax or pneumomediastinum PPHN - persistent pulmonary hypertension of the newborn Cerebral palsy - due to cerebral hypoxia Chronic lung disease - develop from barotrauma and oxygen toxicity ```
51
Define failure to thrive
Poor physical growth and development in a child - 1+ centile spaces if birthweight below 9th centile - 2+ centile spaces if birthweight between 9th and 91st centile - 3+ centile spaces if birthweight above 91st centile
52
Causes of failure to thrive
``` Inadequate nutritional intake - maternal malabsorption if breastfeeding - iron deficiency anaemia - family or parental problems - neglect - availability of food Difficulty feeding - poor suck - cleft lip or palate - pyloric stenosis Malabsorption - CF - coeliac disease - cow's milk intolerance - chronic diarrhoea - IBD Increased energy requirements - hyperthyroidism - chronic diseases - malignancy - chronic infections Inability to process nutrition - inborn errors of metabolism - DM T1 ```
53
Types of learning disabilities
Dyslexia - difficulty reading, writing and spelling Dysgraphia - difficulty writing Dyspraxia - developmental co-ordination disorder Auditory processing disorder Non-verbal learning disability Profound and multiple learning disability
54
Define Down's syndrome
Trisomy 21 - 3 copies of chromosome 21
55
Dysmorphic features of Down's syndrome
Hypotonia (reduced muscle tone) Brachycephaly (small head with a flat back) Short neck Short stature Flattened face and nose Prominent epicanthic folds - folds of skin over the medial portion of the eye and eyelid Upward sloping palpable fissures - gaps between lower and upper eyelid Single palmar crease
56
Complications of Down's syndrome
Learning disability Recurrent otitis media Deafness - Eustachian tube abnormalities lead to glue ear and conductive hearing loss Visual problems - myopia, strabismus and cataracts Hypothyroidism Cardiac defects - ASD, VSD, patent ductus arteriosus and tetralogy of Fallot Atlantoaxial instability Leukaemia is more common in children with Down’s Dementia is more common in adults with Down’s
57
Antenatal screening for Down's sydnrome
Combined test - performed between 11 and 14 weeks - USS measures nuchal translucency - over 6 mm - beta-human chorionic gonadotrophin (beta-HCG) - high - pregnancy-associated plasma protein-A (PAPPA) - low Triple test - 14 and 20 weeks gestation - Beta-HCG - Alpha-fetoprotein (AFP) - low - Serum oestriol (female sex hormone) - low
58
Define cerebral palsy
Non-progressive, permanent impairment of motor-postural development neurological problems resulting from damage to the immature brain
59
Causes of cerebral palsy
``` Antenatal - maternal infections - trauma Perinatal - birth asphyxia - pre-term birth - intraventricular haemorrhage Postnatal - meningitis - severe neonatal jaundice - head injury ```
60
Types of cerebral palsy
``` Spastic - hypertonia and reduced function - upper motor neurons Dyskinetic - Athetoid = abnormal, involuntary movements affecting extremities, facial grimacing and drooling, feeding and speech impairment, hypotonia, normal reflexes - Dystonic - prolonged, slow, repetitive movements, abnormal posturing, hypotonia and normal reflexes - damage to basal ganglia Ataxic - problems with coordinated movement - damage to cerebellum Mixed ```
61
Patterns of Spastic Cerebral palsy
Monoplegia - one limb Hemiplegia - one side on body affected Diplegia - four limbs affected - mostly legs Quadriplegia - four limbs affected
62
Presentation of cerebral palsy
Failure to meet milestones Increased or decreased tone, generally or in specific limbs Hand preference below 18 months Problems with coordination, speech or walking Feeding or swallowing problems Learning difficulties
63
Gait features
``` Hemiplegic / diplegic gait = upper motor neurone lesion Broad based gait / ataxic gait = cerebellar lesion High stepping gait = foot drop or a lower motor neurone lesion Waddling gait = pelvic muscle weakness due to myopathy Antalgic gait (limp) = localised pain ```
64
Features of upper motor neurone lesion
Muscle bulk preserved Hypertonia Slightly reduce power Brisk reflexes
65
Features of lower motor neurone lesion
Reduced muscle bulk and fasciculations Hypotonia Dramatically reduced power Reduced reflexes
66
Complications/associated conditions of cerebral palsy
``` Learning disability Epilepsy Kyphoscoliosis Muscle contractures Hearing and visual impairment Gastro-oesophageal reflux ```
67
Mx of cerebral palsy
MDT approach - physio - occupational therapy - speech and language - dieticians - orthopaedic surgeons - tenotomy - paediatrician - muscle relaxants - anti-epileptic drugs - glycopyrronium bromide - excessive drooling
68
Define autsim
Spectrum of conditions which affect social and communication skills
69
Rks factors for ASD
Male sex FHx Fragile X syndrome
70
Clinical features of ASD
Social skills - poor eye contact, difficulty empathizing, social cues being missed, lack of imaginative play Language - speech delay, literal interpretation of language, restricted gestures and facial expressions, echolalia Repetitive behaviour - hand flapping, tiptoe gait, unusual interests, strict routine adherence
71
Mx of ASD
Biological - co-morbidities - community paediatrician coordinates - antipsychotics for aggression - risperidone - melatonin for severe sleep dysregulation Psychological - support groups and counselling for family - psychological comorbidities common Social - applied behavioural analysis - education support at school
72
Define ADHD
Presence of hyperactivity, impulsiveness and inattention
73
Risk factors for ADHD
Male Fhx of ADHD, learning difficulties or substance misuse In utero exposure to alcohol/nicotine
74
Clinical features of ADHD
Inattention Hyperactivity Impulsiveness Usually present with concerns raised by school staff or parents or difficulty with schooling/school refusal
75
Mx of ADHD
``` MDT approach Social - behaviour management centred around routines and consistency - positive reinforcement - parental training Biological - Methylphenidate - CNS stimulant ```
76
Side effects of methylphenidate
``` Anxiety Tremors Hypertension Insomnia Anorexia Hyperhidrosis ```
77
Method of action of methylphenidate
Blocks both dopamine and noradrenaline transporters on synaptic membrane Inhibits reuptake of dopamine and noradrenaline Net increase in dopamine and noradrenaline in neuronal synapses Increased neurotransmission of substances
78
Foetal circulation
Oxygenated blood carried through umbilical vein - enters foetal circulation via ductus venosus into inferior vena cava IVC drains into the right atrium - foraeman ovale patent - shunts most blood from right to left - right sided pressure greater than left - shunted blood bypasses lungs Some blood remains on right side leaves via pulmonary artery - blood flows through patent ductus arteriosus between pulmonary artery and aorta Deoxygenated blood flows back to placenta via umbilical arteries
79
Circulation changes during birth
Removal of placenta Onset of breathing Rapid reduction in pulmonary vascular resistance Closure of shunts - ductus arteriosus, ductus venosus and foramen ovale Physiology - amniotic fluid in lungs displaced by squeezing within birth canal - onset of breathing increases PaP2 and normalises pH and PaCO2 - induce pulmonary vasodilation and reduce pulmonary resistance - clamping umbilical cord immediately increases systemic vascular resistance - left atrial pressure now exceeds right atrial pressure -> foramen ovale closes - Increase in PaO2 triggers closure of ductus arteriosus
80
GI tract changes
Develops as a tube from 6 weeks gestation Foetus swallows amniotic fluid from 16 weeks gestation - proteins from mother including antibodies transferred to feotus Nutrients absorbed via gut from 25 weeks gestation Coordination of suck and swallow develops after 34 weeks gestation
81
Hepatic function changes
Neonatal liver has little function - toxin filtering and metabolism are performed by placenta After birth liver adjusts but will not reach full capacity for a few months - neonatal drugs given at low doses because of immaturity in metabolic function
82
Define perinatal mortality rate
Number of still births and neonatal deaths within first week of life per 1000 live births
83
Define neonatal mortality rate
Total deaths per 1000 live births in first 28 days
84
Risk factors for prematurity/IUGR
``` Multiple pregnancy Maternal illness Placental insufficiency In utero infection Genetic disorder ```
85
Types of IUGR
Symmetrical - IU infections and chromosomal abnormalities - proportionally small head, length and weight Asymmetrical - maternal or placental issues - placental insufficiency or pre-eclampsia - small length and weight, with preserved head size
86
Define prematurity
Any birth before 37/40
87
Define IUGR
Failure of foetus to achieve genetic growth potential
88
Define SGA
Small for gestational age | Newborn below certain centile for particular gestation - usually 10th centile
89
Define LBW
Low birth weight | - less than 2500g
90
Define VLBW
Very low birth weight | - less than 1500g
91
Define stillbirth
Foetus born after 24/40 that never shows signs of life
92
Define neonatal death
Death of newborn within 28 days of delivery
93
Define hypoglycaemia
Blood sugar < 2.6 mmol/L
94
Causes of hypoglycaemia of the newborn
``` Reduced glucose production - preterms - metabolic errors Increased glucose demands - sepsis - hypothermia Hyperinsulinism - diabetic mother Endocrine problems ```
95
Mx of hypoglycaemia of newborn
1.6-2.6 mmol/L and asymptomatic - feed infant - consider increasing feed frequency Severe (<1.6 mmol/L) or symptomatic - IV dextrose - admit to neonatal unit and monitor blood sugars hourly till stable - hypo screen - identify common endocrine and metabolic aetiologies
96
Define RDS
Respiratory distress syndrome - hyaline membrane disease - condition of prematurity caused by insufficient levels of surfactant - manifests as a tachypnoeic newborn
97
Pathophysiology of RDS
Lack of surfactant in the lungs due to prematurity or effect inhibited by asphyxia - surfactant lowers alveolar surface tension - loss of surfactant results in alveolar collapse
98
Risk factors for RDS
``` Prematurity Perinatal asphyxia - difficult birth - meconium aspiration - sepsis - congenital lung abnormalities Maternal diabetes - delayed lung maturity ```
99
Clinical features of RDS
``` Distressed and unwell infant Poor feeding Tachypnoea > 60 breaths per minute Hypoxia Respiratory distress - intercostal and subcostal recession, head bobbing, tracheal tug and nasal flaring Grunting ```
100
Mx of RDS
Oxygen - aiming for pO2 6-10 CPAP and mechanical ventilation Artificial surfactant - increase lung compliance and decrease alveolar surface tension
101
Define IVH
Intraventricular hemorrhage - alteration in cerebral blood flow results in bleeding in the fragile germinal matrix - if severe enough spreads to ventricles - most commonly before 32 weeks as germinal matrix disappears in 3rd trimester
102
Define PVL
Periventricular leukomalacia | - hypoperfusion and excitotoxic cytokines causes damage to oligodendroglia resulting in white matter injury
103
Risk factors for neonatal brain injury
``` VLBW Gestation less than 32 weeks Difficult birth RDS Cardiovascular instability Other prematurity complications ```
104
Clinical features of IVH
``` Often asymptomatic Seizures and apnoeas with big bleeds Floppy infant with poor feeding Abnormal movements or tone Large IVH may present with hypovolaemic neonate - tachycardia, peripherally shut down ```
105
Mx of IVH
ABCDE approach | Maintain good blood pressure and oxygen/CO2 level control
106
Mx of PVL
Aim is prevention - avoiding large blood pressure fluctuations and hypoxia
107
Grades of IVH
Grade 1 - isolated to germinal matrix Grade 2 - haemorrhage into ventricles, no dilation Grade 3 - haemorrhage into ventricle with acute dilation Grade 4 - parenchymal haemorrhagic infarct
108
Risk factors for neonatal infection
``` Prematurity Maternal pyrexia in labour Premature rupture of membranes (PROM) LBW Long lines in situ Chorioamnionitis Maternal group B strep colonization ```
109
Clinical features of neonatal infection
Clinically deteriorating neonate Poor feeding Obs deranged - HR and BP late changes Crepitations, bowel sounds, organomegaly, rash, abdo distended, fontanelle sunken or bulging
110
Mx of neonatal infection
Abx treatment - commenced < 1 hour of suspicion - early onset (<72 hours) = IV penicillin + IV aminoglycoside - late onset (>72 hours) = IV flucloxacillin + IV aminoglycoside - acyclovir to cover potential HSV infection
111
RF for NEC
``` ORal feeding - formula higher risk than breast milk PRematurity Concurrent infection LBW/VLBW IUGR Perinatal asphyxia ```
112
Causes of neonatal jaundice
``` Less than 24 hrs = haemolytic or infection - haemolytic disease of the newborn - ABO or rhesus incompatibility - G6PD deficiency - hereditary spherocytosis - alpha thalassemia 24 hours - 14 days = physiological - immature liver - high haemoglobin levels Longer than 14 days - breast milk jaundice - biliary atresia - infection ```
113
Define kernicterus
Bilirubin encephalopathy
114
Pathophysiology of kernicterus
Result of excess unconjugated bilirubin crossing the BBB | Any illness causing systemic acidosis disrupts the BBB making kernicterus more likely
115
Risk factors for kernicterus
High unconjugated bilirubin Sepsis Acidosis
116
Complications of kernicterus
Cerebral palsy Deafness Intellectual disability
117
Pathophysiology of cleft lip/palate
Normal development of facial structures interrupted in utero - lip and nose develop between 3rd and 7th week - palate forms between th and 12th week - interruptions before the 7th week will result in cleft left which will extend into primary (anterior) portion and after 8th week will result in a cleft of larger secondary portion
118
Risk factors of cleft lip/palate
Aneuploidy/genetic syndrome FHx Maternal drug use, smoking and alcohol
119
Symptoms of cleft lip
Difficulty establishing feeds Recurrent chest infections - from aspirations Faltering growth
120
Mx of cleft lip/palate
Medical - MDT - paediatrician, SALT, maxillofacial surgeon, orthodontist, ENT, cleft nurse specialist, geneticist - feeding support Surgical - lip repair around 3 months - palate repair at 6-12 months - further orthodontic surgery - long term follow up for ENT - otitis media and Eustachian tube difficulties Psychological - reassure that surgical outcomes are good - support groups - CLAPA and Operation Smile
121
Pathophysiology of spina bifida
Brain and spinal cord develop from ectoderm-derived neural tube Failure of caudal end of tube to close - normally closes days 17-30 of gestation
122
Types of spina bifida
Spina bifida occulta (SBO) - vertebral arch defect with an intact spinal cord - clinically apparent as a hairy patch of skin over area - no neurological defect Meningocele - vertebral arch defect with herniation of the meninges but no the spinal cord - covered with skin - prognosis following surgery is good - < 10% developing neurological impairment or hydrocephalus Myelomeningocele - thoracolumbar defect with herniation of the meninges and spinal cord - only meninges covering neural tissue - no skin - prognosis depends on level and extent of lesion
123
Risk factors for spina bifida
Maternal folic acid deficiency - up to 50% of cases Maternal medications - anti-epileptics Maternal diabetes Fhx
124
Mx of spina bifida
Medical - for severe defects - MDT management at tertiary centre - neurosurgeons, paediatricians, orthopaedics, urology, child development, psychology - mx of neuropathic bladder Surgical - meningocele and myelomeningocele managed with surgical closure - close monitoring for development of hydrocephalus Psychosocial - specialist nurses and early psychological support

Yr4 - Paeds (16 decks)

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