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Neonatology & Common postnatal problems Flashcards

1
Q

When does the CVS begin to develop?

A

Begins to develop 3rd week

Heart starts to beat at the beginning of 4th week

Critical period heart development is from day 20 to day 50 after fertilisation

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2
Q

What is the patent ductus arteriosus between?

A

Pulmonary artery to aorta

  • Protects lungs against circulatory overload
  • Allows the tight ventricle to strengthen
  • Carries low O2 saturated blood
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3
Q

What is the ductus venosus and what is the role of it?

A

Foetal blood vessel connecting the umbilical vein to the IVC (blood flow regulated via sphincter)

Carries mostly oxygenated blood from the placenta into the body of the foetus

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4
Q

How long does it take for the ductus arteriosus to close after first breath?

A

Usually takes up to 6 hrs but sometimes it could take up to 72 hrs

In a small amount it doesn’t close at all q

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5
Q

How long does it take for the ductus arteriosus to close after first breath?

A

Usually takes up to 6 hrs but sometimes it could take up to 72 hrs

In a small amount it doesn’t close at all

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6
Q

What is the normal HR of a newborn?

A

120-160 BPM

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7
Q

How do newborns do thermoregulation?

A

Newborn babies lack shivering thermogenesis thus need a metabolic production of the heat

Brown fat is well innervated by sympathetic neurons

Cold stress leads to lipolysis and heat production

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8
Q

How can we lose heat and what is done to prevent this?

A

Radiation:
Heat dissipated to colder objects.
Convection:
Heat loss by moving air.
Evaporation:
We are born in the water.
Conduction:
Heat loss to surface on which baby lies

Resuscitaire-preheated, hat available, sides up to prevent draft, warm towels for drying baby, all warm environment

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9
Q

How can newborn breathing be assessed?

A

Non invasive:
Blood gas determination
- PaCO2 5-6 kPa, PaO2 8-12 kPa
Trans-cutaneous pCO2/O2 measurement

Invasive (intubated baby):
Capnography
Tidal volume 4-6 ml/kg
Minute ventilation: Tidal Volume ml/kg x respiratory rate
Flow-volume loop.

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10
Q

What is physiological jaundice and how long does it last?

A

Appears on Day of life (DOL) 2-3-Disappears within 7-10 DOL in term infants and up to 21 DOL in premature infants.

Up to 60% terms and 80% premature babies develop visible jaundice.

75% bilirubin comes from haemoglobin-Metabolised, conjugated in liver.

Bilirubin is lipid soluble thus crosses haemato-encephalic barrier.
At high concentrations it cause an irreversible changes in the brain – kernicterus.

Blue light converts bilirubin to water soluble form and increases oxidation of bilirubin.

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11
Q

What is normal in terms of fluid balance in the term newborn?

A

Full term infant is able to maintain fluid / electrolyte balance.

Weight loss up to 10% is normal.
Loss is due to:
- Shift of interstitial fluid to intravascular
- Diuresis

It is normal not to pass urine for the first 24 hrs!

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12
Q

In premature infants they have less fat in body composition. Why do they have increased loss of fluid?

A

Increased loss through kidney:
- Slower GFR
- Reduced Na reabsorption
- Decreased ability to concentrate or dilute urine

Increased Insensible Water Loss (IWL)
- Via immature skin and breathing
- Physiological IWL is 20-40 ml/kg/day but could be up to 82 ml/kg/day in 750-1000 g

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13
Q

How does the physiological anaemia of the newborn occur?

A

RBC production is 10% of in uterus DOL 7

Born with - Hb 15-20 g/l
Week 10 - Hb 11.4 g/l
Increase production of Erythropoietin
Week 20 - Hb 12.0 g/l

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14
Q

What can cause anaemia of prematurity?

A

Reduced erythropoesis.

Infection

Blood letting – most
important cause!

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15
Q

When is term classified?

A

Babies born at 37 weeks gestation and above

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16
Q

What are the symptoms of sepsis to look out for in a newborn?

A

Symptoms
Baby pyrexia or hypothermia
Poor feeding
Lethargy or irritable
Early jaundice
Tachypnoea
Hypo or hyperglycaemia
Floppy
Asymptomatic

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17
Q

What are the symptoms of sepsis to look out for in a neonate?

A

Symptoms
Baby pyrexia or hypothermia
Poor feeding
Lethargy or irritable
Early jaundice (first 24hrs)
Tachypnoea
Hypo or hyperglycaemia
Floppy
Asymptomatic

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18
Q

What are the risk factors for sepsis in a newborn?

A

PROM (waters broken for >24hrs before baby delivered-risk of chorioamnionitis)
Maternal pyrexia
Maternal GBS carriage

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19
Q

How is presumed sepsis of a neonate managed?

A

Admit NNU

Partial septic screen (FBC, CRP, blood cultures) and blood gas

Consider CXR, LP

  • IV penicillin and gentamicin 1st line
  • 2nd line IV vancomycin and gentamicin
  • Add metronidazole if surgical/abdominal concerns

Fluid management and treat acidosis
Monitor vital signs and support respiratory and cardiovascular systems as required

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20
Q

What are the commonest causes of neonatal sepsis?

A

1) Group B strep
2) E.coli
2) Listeria
4) Coag-neg Staph (if lines in situ)
5) Haemophilus influenzae

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21
Q

GBS Sepsis: when is early and when is late onset and what are the complications of it?

A

Early onset – birth to 1 week
Late onset or recurrence – up to 3 months

Symptoms – may be non specific
May have no risk factors

Complications:
Meningitis, DIC, pneumonia and respiratory collapse, hypotension and shock

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22
Q

What is the TORCH screen for congenital infection?

A

Toxoplasmosis (undercooked meat and handling cat litter)
‘Other’ (syphilis & VZV)
Rubella
Cytomegalovirus (CMV)
Herpes simplex virus (HSV)

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23
Q

What may congenital infections result in?

A

IUGR, brain calcifications, neurodevelopmental delay, visual impairment, recurrent infections

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24
Q

What is blueberry muffin rash (purple papulonodular rash) typically seen in?

A

Rubella

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25
Resp distress is one of the commonest reasons for admission to NNU: what are the causes of it?
- Sepsis - TTN-transient tachypnoea of the newborn - Meconium aspiration
26
What are some signs of resp distress?
- Subcostal recessions - Grunting (expiring against a partially closed glottis)
27
When does TTN present and what is the management of it?
Self limiting and common Presents within 1st few hours of life Grunting, tachypnoea, oxygen requirement, normal gases Pathophysiology Delay in clearance of foetal lung fluids Management Supportive, antibiotics, fluids, O2, airway support
28
What can be seen on a CRX in TTN?
Wet lungs with prominent vascular markings Fluid in the horizontal fissure
29
What is meconium aspiration and what are the symptoms?
Meconium is inhaled into the lungs Symptoms: - Cyanosis - Increased work of breathing - Grunting - Apnoea - Floppiness
30
What are the risk factors for meconium aspiration?
- Post dates (Term +) - Maternal diabetes - Maternal HT - Difficult labour
31
How do you investigate for meconium aspiration?
- Blood gas - Septic screen - CXR
32
What is the treatment and prognosis of meconium aspiration?
Treatment: - Suction below cords - Airway support - intubation and ventilation - Fluids & Abx IV - Surfactant - NO (vasodilator) or ECMO (lung bypass) Prognosis: - Most do well - Some develop PPHN - Associated mortality
33
Most cardiac murmurs of no consequence & don't need admission to NNU, which ones do?
Them blue babies -need urgent treatment (sepsis and resp distress causes more common than cardiac)
34
What is done to investigate blue babies?
- H&E - Sepsis screen - Blood gas & BG - CXR - Pulse oximetry - ECG - ECHO - (hyperoxia test- breathe 100% O2 to help differentiate between cardiac and lung disease)
35
What are some main causes of cyanotic congenital cardiac disease (5 T's!!!)
Truncus arteriosus TGA Tricuspid atresia ToF TAPVD
36
What weight category shows that a baby is born small?
<2.5kg
37
What weight category shows that a baby is born small?
<2.5kg (small for gestational age) Small for gestational age is the babies born under the weight of the 10th centile - Small for gestational age (SGA) - IUGR
38
What are some maternal problems that could make a baby small for dates?
- Smoking - Maternal pre-eclamptic toxaemia (PET)
39
From the foetal point of view what could make a baby small for dates?
- Chromosomal e.g. Edward's syndrome (Trisomy 18) - Infection e.g. CMV
40
What can go wrong with placenta that can make a baby small for dates?
- Placental abruption
41
Twin pregnancy can be a reason for babies being small for dates. Is this true?
Yes it is indeedy - Twin to twin transfusion - Donor babies usually smaller
42
What are some common problems that the babies experience who are small for dates?
- Perinatal hypoxia - Hypoglycaemia - Hypothermia - Polycythaemia - Thrombocytopaenia - GI problems (feeds, NEC)
43
What is extreme preterm?
Under 1 kg, & under 28 weeks
44
RDS (caused by surfactant deficiency): How can it be prevented and treated?
Prevention - Antenatal steroids Early treatment - Surfactant Early extubation Non-invasive support (N-CPAP) Minimal ventilation (low tidal volume & good inflation)
45
BPD/CLD is a complication of RDS: what causes it and how is it treated?
Overstretch by volu-baro-trauma Atelectasis Infection via ETT O2 toxicity Inflammatory changes Tissue repair - scarring Treatment: - patience - nutrition & growth - steroids (!)
46
What are some minor problems of the resp system that can occur in preterms?
Apnoea/irregular breathing/desaturations Treatment: - Caffeine - N-CPAP
47
How is IVH prevented and treated?
Prevention AN steroids Treatment=Symptomatic
48
What is PVL?
Injury to white matter in the watershed area
49
What is a major complication of IVH?
PHH (post haemorrhagic hydrocephalus) - blood products block draining system of CSF in the brain Treatment= Ventricular peritoneal shunts
50
What can happen with a PDA in preterm infant?
Pressure Ao>PA - L to R shunt: Additional blood to pulmonary circulation - over-perfusion of lugs - lung edema + steal from systemic circulation - systemic ischemia
51
What are the consequences of a PDA?
Worsening of respiratory symptoms + Retention of fluids (low renal perfusion) Gastrointestinal problems (GE ischemia-become susceptible for NEC)
52
What is NEC caused by and what is the management?
Ischemic & inflammatory changes Necrosis of bowel Surgical intervention is often required Conservative management is sometimes possible=antibiotics & parenteral nutrition
53
There is enormous nutritional requirements in preterm, why is this?
Patients often triple their size during hospital stay Building new functional tissues from compounds provided artificially
54
The outcome of extreme prematurity are unpredictable at the time of birth, how is it predicted later on?
Ultrasound of brain by the end of 1st week Often very uncertain even on discharge home Surprising deterioration (cognitive and behavioural) between year 2nd and year 6th Also some unexpected improvement between 2nd and 6th year of life Extremely limited data on subjective quality of life in adulthood
55
How should Hypoglycaemic term infants be managed who have symptoms of low BG or who have persistent low BG?
If requires admission to NNU may still manage with enteral feeds Monitor blood glucose Start iv 10% glucose Increase fluids Increase glucose concentration (central iv access) Glucagon Hydrocortisone
56
What should be done in a case of Hypothermia?
If unable to maintain temp on PNW admit and place in incubator Sepsis screen & Abx Consider checking thyroid function (congenital hypothyroidism) Monitor BG
57
What may be required in a case of severe jaundice?
Admission for intensive phototherapy &/or exchange transfusion Incubator & IV fluids may be required
58
What is birth asphyxia and what can cause it?
Lack of O2 at or around birth leads to multiorgan dysfunction Causes: - Placental problem - Long, difficult delivery - Umbilical cord prolapse - Infection - Neonatal airway problem - Neonatal anaemia
59
What are the stages of birth asphyxia?
1st=Within minutes=cell damage occurs with lack of BF & O2 2nd= Reperfusion injury-can last days or weeks=toxins are released from damaged cells
60
What is hypoxic ischaemic encephalopathy?
The pattern of brain injury that occurs secondary to birth asphyxia Diagnosis based on biochemical evidence of birth asphyxia - found on cord blood gases that should be taken at the time of delivery & also blood gases found shortly after delivery - Abnormalities on neuro exam Mild, moderate or severe HIE
61
What is the management of HIE?
- Supportive care - Therapeutic hypothermia(cooling) improves outcome esp in moderate group - Treat seizures (also look for subclinical seizure) - Fluid restriction (avoid cerebral oedema) - Resp & cardiac support
62
What are some causes of failure to pass stool?
Large bowel atresia Imperforate anus +/- fistula Hirschsprung's disease Meconium plug Meconium ileus -think CF
63
What are 2 common abdominal wall defects seen that are a surgical problem?
Exomphalos (Herniation of abdo contents covered by a sac)-associated commonly with a congenital anomaly (most commonly cardiac) Gastroschisis (Herniation of bowel contents not covered by a protective sac)-tends to be an isolated defect
64
Congenital diaphragmatic hernia: what is is caused by and how is it managed?
Defect in the formation of the diaphragm which means the bowel contents herniates up into the chest-essentially this becomes a problem with lung development 90% on left Male > female - Can be syndromic - Usually pulmonary hypoplasia Intubation at birth Respiratory support Surgery after NG tube to decompress bowel (ECMO)
65
On what side is the congenital diaphragmatic hernia most likely to occur?
90% on left
66
What is neonatal abstinence syndrome (NAS)?
Withdrawal from physically addictive substances taken by the mother in pregnancy Opioids (methadone, heroin) Benzodiazepines Cocaine Amphetamines
67
How is NAS diagnosed and treated?
Monitoring/Diagnosis: Finnegan Scores (looking for features of NAS) Urine toxicology Maternal co-morbidity (smoking, alcohol, BBV, ill health) Social & discharge planning Treatment: Comfort (e.g. swaddling) Morphine (isolated opioid use in mother) Phenobarbitone (poly drug abuse or use to treat more severe cases)
68
If sepsis is suspected when should you start Abx?
Within 1 hr
69
RR>60 or signs or RDS are common reasons for admission what could they point towards?
Mild=TTN Severe=MAS, Sepsis
70
When is the top to toe newborn examination done?
Within 72 hrs of their birth
71
What is plethora?
Reddy skin colour-may be due to abnormalities of blood vessels in utero, polycythaemia etc Bloods-look at haematocrit
72
When is blue peripheries normal?
Extremely common in the newborn period and is part of the normal transition
73
Why does physiological jaundice occur?
Increased red cell turnover so bilirubin is produced from the breakdown of Haem in red blood cells & also immaturity of hepatic enzymes which process bilirubin Normal physiological jaundice causes an unconjugated hyperbilirubinemia
74
When does physiological jaundice occur?
Between 2nd day of life and 2nd week in term or 3rd week in pre-terms
75
Why is it important to check the conjugated bilirubin factor in cases of prolonged jaundice?
As cholestasis would be identified by conjugated jaundice
76
How is jaundice treated?
- Treat underlying causes - Hydrate - Phototherapy-NICE guideline charts (based on gestation) - Exchange transfusion - Immunoglobulin
77
Why does physiological type jaundice often get treated?
Unconjugated bilirubin levels if they become too high can cause neuro-toxic effects
78
What is erythema toxicum?
Maculo-papular rash Very rare in pre-term Rash fades by end of 1st week No Rx is required
79
Mongolian blue spots (blue-grey pigmentations) are very common: what are they caused by and where are they often seen?
- Accumulation of melanocytes - Very common- races with pigmented skin-less obvious as skin darkens - Often: Lower back + buttocks
80
Stork marks (Naevus Simplex)-are caused by what and where are they commonly found?
Light colour capillary dilation commonly found at back of neck (maybe along midline of face) Gradually fades within the first 2 yrs
81
Naevus flammeus (port wine stain) do not regress: what are they caused by and what is it associated with?
Present at birth, flat or slightly raised Caused by dilated, mature capillaries in the superficial dermis Associations: - Sturge Weber - Klippel-Trenaunay
82
What is a capillary haemangioma (strawberry naevus)?
A cluster of dilated capillaries which appears within the first month after birth Raised & bright red, with discrete edges, occurring in any part of the body Usually regresses after 1yo (B blocker treatment if needed)
83
What does the energy triangle involve (think warm, pink and sweet)?
Pillars of new-born care are to avoid: - Hypothermia - Hypoxia/anoxia - Hypoglycaemia
84
Why are newborns more susceptible to hypothermia?
High surface area to volume ratio, born wet and they come into contact with cold environments & surfaces
85
How is resuscitation and cold stress managed?
- Dry quickly - Remove wet linens - Use warm towels/blankets - Provide radiant warmer heat - Use heated/humidified O2
86
What is hypoglycaemia in the first 48 hrs of life of a term baby defined as?
BG < 2mmol/l
87
When could BG bedside testing be inaccurate?
- At low or high levels - When there is poor perfusion - When there is polycythaemia (high Hct) Check a lab sample if there are concerns
88
What babies are at risk of hypoglycaemia?
- Limited Glc supply (premature babies, perinatal stress) - Hyperinsulinism, (infants of diabetic mothers) - Increased Glc use (hypothermia, sepsis)
89
What are some symptoms of Hypoglycaemia?
- Jitteriness - Temp instability - Hypotonia - Apnoea, irregular resps - High pitched or weak cry - Seizures - Asymptomatic
90
What is tongue tie and when should it be treated (mostly no treatment necessary)?
Short +/- thickened frenulum- attached anteriorly to base of tongue Restriction of tongue protrusion beyond the alveolar margins AND feeding is affected=Frenotomy
91
Bilious vomiting (fairy liquid green) is what until proved otherwise?
Bowel obstruction
92
How do you evaluate a newborns resp?
- RR (>60 min) - Increased effort (grunting, retractions, nasal flaring) - Colour - O2 saturations
93
Where are the areas to assess for retractions (resp)?
Substernal Subcostal Intercostal Suprasternal
94
Why is it important to check for absent/weak femoral pulses?
Can indicate coarctation of the aorta (duct dependant cardiac disease) (Look at BPs in arms and legs, ECG as investigations)
95
What are the categories of cleft lip and what causes them?
70% of cases also have cleft palate Can be incomplete (small gap in lip) or complete (continue into the nose) Can be unilateral (left sided most common) or bilateral Maxillary & medial nasal processes fail to merge, usually around 5 weeks gestation
96
What are the issues and associated anomalies of cleft palate/lip?
- Feeding issues (special bottles & teats, can still attempt breast feeding) - Airway problems - Associated anomalies: need hearing screen and cardiac echo and remember trisomies
97
What ophthalmological conditions are screened for in newborns?
Always check red reflexes CATARACTS (lens opacification, if undetected early could lead to blindness, may require lens removal and artificial lens) RETINOBLASTOMA (leukocoria (red white reflex)- cancer which can be treated if picked up early-laser therapy, chemo, surgical removal of the eye)
98
What can spinal dimples show?
Can reveal a more serious abnormality involving the spine &/or spinal cord such as spina bifida occulta which is the least serious form of spina bifida +/- tethered cord If the dimple is large, off midline, high or with other cutaneous marker (e.g. hairy tuft)----Spinal imaging
99
What is a cephalohematoma and what is the treatment?
Localised swelling over one or both sides of the head-becomes maximal size by the 3rd to 4th day of life Soft, non translucent swelling-limits are those of one of the cranial bones-usually parietal bone-haemorrhage is beneath the pericranium No treatment is required and resolution occurs in 3-4 weeks No association with intracranial bleeding
100
Cephalohematoma: What occasionally if the haematoma is very large what can occur?
Increased haemolysis results in increased or prolonged neonatal jaundice
101
What do talipes require as treatment?
Medial (varus) or lateral (valgus) deviation of the foot is often positional and requires no treatment other than physio Fixed talipes require more vigorous manipulation, strapping, casting or possible surgery
102
Babies with significant talipes may also have?
Developmental dysplasia of the hips (DDH)
103
What are the tests for DDH?
Barlow Test (adduct hip, backwards pressure to see if joint will slip out) Ortolani test (abduct hip- already dislocated slip back into place) Urgent USS if hear click or a clunk
104
What is the DDH treatment?
Goal is to relocate head of femur to acetabulum so hip develops normally Pavlik harness Surgical reduction
105
What are the signs of Trisomy 21?
Dysmorphism (low set ears, upward slanting palpebral fissures, epicanthic folds, single palmar creases, wide sandal gap) Hypotonia (floppy baby-decreased muscle tone) Cardiac defects Learning Problems Haematological problems Thyroid problems

Paediatrics (17 decks)

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