Neonatology: Sepsis; Jaundice; Apnoeas Flashcards
TOM TIP: With neonate sepsis, the organism to remember for your exams is [] This is a common bacteria found in the vagina. It does not cause any problems for the mother, but can be transferred to the baby during labour and cause neonatal sepsis.
TOM TIP: The organism to remember for your exams is group B strep (GBS). This is a common bacteria found in the vagina. It does not cause any problems for the mother, but can be transferred to the baby during labour and cause neonatal sepsis. Prophylactic antibiotics during labour are used to reduce the risk of transfer if the mother is found to have GBS in their vagina during pregnancy.
What are red flags for neonatal sepsis [6]
- Confirmed or suspected sepsis in the mother
- Signs of shock
- Seizures
- Term baby needing mechanical ventilation
- Respiratory distress starting more than 4 hours after birth
- Presumed sepsis in another baby in a multiple pregnancy
How do you treat for presumed sepsis in neonate? [7]
- If there is one risk factor or clinical feature, monitor the observations and clinical condition for at least 12 hours
- If there are two or more risk factors or clinical feature of neonatal sepsis start antibiotics
- Antibiotics should be started if there is a single red flag
- Antibiotics should be given within 1 hour of making the decision to start them
- Blood cultures should be taken before antibiotics are given
- Check a baseline FBC and CRP
- Perform a lumbar puncture if infection is strongly suspected or there are features of meningitis (e.g. seizures)
Always check your local antibiotic policy. The NICE guidelines (2012) recommend [2] as first line antibiotics for neonatal sepsis [2]
Alternatively [1] may be given as an alternative in lower risk babies.
Always check your local antibiotic policy. The NICE guidelines (2012) recommend benzylpenicillin and gentamycin as first line antibiotics.
Alternatively a third generation cephalosporin (e.g. cefotaxime) may be given as an alternative in lower risk babies.
When do you check CRP for ongoing neonate sepsis management? [3]
Initial treatment:
* Check CRP at 24hrs
* Check blood culture results at 36 hours
* Consider stopping the abx if baby is clinically well and blood cultures are negative 36hrs after taking AND both CRPs are < 10.
Check CRP again at 5 days if still on tx:
- Consider stopping antibiotics if the baby is clinically well, the lumbar puncture and blood cultures are negative and the CRP has returned to normal at 5 days.
Neonatal sepsis:
Consider [investigation] if any of the CRP results are more than 10.
Consider performing a lumbar puncture if any of the CRP results are more than 10.
Neonatal jaundice:
Conjugated bilirubin is excreted in which two ways? [2]
Conjugated bilirubin is excreted in two ways: via the biliary system into the gastrointestinal tract and via the urine.
Describe bilirubin metabolism [+]
Bilirubin, bound to albumin goes to liver, where it is conjugated
Conjugated bilibrubin is excreted in bile, where most is excreted in faeces as stercobolin, or in urine as urobilin, some reenters the enterohepatic circulation
Describe the overall causes of neonatal jaundice [2]
The causes of neonatal jaundice can be split into increased production or decreased clearance.
Describe risk factors for jaundice in neonates [+]
- Premature infants, LBW
- Asian ethnicity
- Male infants
- G6PD or ABO incompatbility
- Previous sibling
- Exclusive breastfeeding
- Cephalohaematoma
The causes of neonatal jaundice can be split into increased production or decreased clearance.
What are 5 causes of increased production of bilirubin in neonates? [5]
Haemolytic disease of the newborn
ABO incompatibility
Haemorrhage
Intraventricular haemorrhage
Cephalo-haematoma
Polycythaemia
Sepsis and disseminated intravascular coagulation
G6PD deficiency
The causes of neonatal jaundice can be split into increased production or decreased clearance.
What are 5 causes of decreased clearance of bilirubin in neonates? [5]
Decreased clearance of bilirubin:
* Prematurity
* Breast milk jaundice
* Neonatal cholestasis
* Extrahepatic biliary atresia
* Endocrine disorders (hypothyroid and hypopituitary)
* Gilbert syndrome
TOM TIP: Jaundice in the first [] hours of life is pathological. This needs urgent investigations and management. Neonatal [] is a common cause.
TOM TIP: Jaundice in the first 24 hours of life is pathological. This needs urgent investigations and management. Neonatal sepsis is a common cause. Babies with jaundice within 24 hours of birth need treatment for sepsis if they have any other clinical features or risk factors.
Why does jaundice occur in premature babies? [1]
This increases the risk of complications, particularly [1].
Explain this complication [1] and how it presents [2]
In premature babies, the process of physiological jaundice is exaggerated due to the immature liver. This increases the risk of complications, particularly kernicterus.
Kernicterus is brain damage due to high bilirubin levels. Bilirubin levels need to be carefully monitored in premature babies, as they may require treatment.
- Bilirubin can cross the BBB and in XS can damage the CNS
- The damage to the nervous system is permeant, causing cerebral palsy, learning disability and deafness. Kernicterus is now rare due to effective treatment of jaundice.
Describe the timeline of jaundice in neonates and potential causes [3]
Jaundice in the first 24 hours is always pathological.
Jaundice in the neonate from 2-14 days is common (up to 40%) and usually physiological
If there are still signs of jaundice after 14 days (21 days if premature) a prolonged jaundice screen is performed
Describe the presentation of acute bilirubin encephalopathy
and chronic encephalopathy (what are the two types?)
Acute encephalopathy;
- Lethargy
- Decreased feeding
- Tone abnormalities
- High pitched crying
- Torticollis
- Opisthotons
- Seizures
Chronic:
Kernicterus:
- Movement disorders
- Auditory dysfunction
- Oculomotor impairment
- Dental dysplasia
Bilirubin induced neurological dysfunction (BIND):
- More subtle neurological impact on vision, hearing and cognitinve behaviourhal impairments
Are babies who are bottle of breastfed more likely to be jaundiced? [1]
Explain why [2]
Babies that are breastfed are more likely to have neonatal jaundice
- Components of breast milk inhibit the ability of the liver to process the bilirubin
- Breastfed babies are more likely to become dehydrated if not feeding adequately. Inadequate breastfeeding may lead to slow passage of stools, increasing absorption of bilirubin in the intestines.
NB: Breastfeeding should still be encouraged, as the benefits of breastfeeding outweigh the risks of breast milk jaundice. Mothers may need extra support and advice to ensure adequate breastfeeding.
When is jaundice always pathological? [1]
Jaundice is “prolonged” when it lasts longer than would be expected in physiological jaundice. This is:
More than [] days in full term babies
More than [] days in premature babies
Always pathological in first 24 hrs
Jaundice is “prolonged” when it lasts longer than would be expected in physiological jaundice. This is:
More than 14 days in full term babies
More than 21 days in premature babies
If a baby has prolonged jaundice, what is the main aim of subsequent investigations? [1]
Main aim of initial investigations is to confirm whether it is a conjugated hyperbilirubinaemia:
* Direct bilirubin of >25 umol/L, or if >20% of total bilirubin
The majority of babies will have an uncomplicated isolated unconjugated hyperbilirubinaemia
Prolonged jaundice should prompt further investigation to look for an underlying cause.
These are particularly looking for conditions that will cause jaundice to persist after the initial neonatal period, such as [4]
Prolonged jaundice should prompt further investigation to look for an underlying cause. These are particularly looking for conditions that will cause jaundice to persist after the initial neonatal period, such as biliary atresia, hypothyroidism and G6PD deficiency.
What is involved in a prolonged jaundice screen? [+]
conjugated and unconjugated bilirubin:
- the most important test as a raised conjugated bilirubin could indicate biliary atresia which requires urgent surgical intervention
direct antiglobulin test (Coombs’ test)
- for haemolysis
TFTs:
- for hypothyroid
FBC and blood film
- polycythaemia or anaemia
urine for MC&S and reducing sugars
- suspected sepsis
Glucose-6-phosphate-dehydrogenase (G6PD) levels
- for G6PD deficiency
Describe the management of neonatal jaundice [2]
In jaundiced neonates, total bilirubin levels are monitored and plotted on treatment threshold charts. These charts are specific for the gestational age of the baby at birth. The age of the baby is plotted on the x-axis and the total bilirubin level on the y-axis. If the total bilirubin reaches the threshold on the chart, they need to be commenced on treatment to lower their bilirubin level.
Phototherapy is usually adequate to correct neonatal jaundice.
Extremely high levels may require an exchange transfusion. Exchange transfusions involve removing blood from the neonate and replacing it with donor blood.
What do you do after stopping phototherapy for jaundice? [1]
Once phototherapy is complete, a rebound bilirubin should be measured 12 – 18 hours after stopping to ensure the levels do not rise about the treatment threshold again.
Define apnoeas in newborns [1]
What are they often associated with? [1]
Apnoea are defined as periods where breathing stops spontaneously for more than 20 seconds, or shorter periods with oxygen desaturation or bradycardia.
- They are often accompanied by a period of bradycardia.
Describe why apnoeas of prematurity occur [1]
Apnoea occur due to immaturity of the autonomic nervous system that controls respiration and heart rate. This system is more immature in premature neonates.
Apnoea are often a sign of developing illness, such as: [5]
- Infection
- Anaemia
- Airway obstruction (may be positional)
- CNS pathology, such as seizures or haemorrhage
- Gastro-oesophageal reflux
- Neonatal abstinence syndrome
How do you manage apnoeas in neonatal units? [2]
Neonatal units attach apnoea monitors to premature babies.
These make a sound when an apnoea is occurring. Tactile stimulation is used to prompt the baby to restart breathing.
Intravenous caffeine can be used to prevent apnoea and bradycardia in babies with recurrent episodes.
What are causes of neonatal jaundice < 24hrs? [3]
Haemolytic disease of the newborn
Infection - TORCH or sepsis
- Start Abx within 24hrs of birth
G6DP deficiency
What are the main causes of neonatal jaundice from day 1 + ? [2]
What are other causes? [+]
Physiological jaundice
Breast milk jaundice
How do you test for haemolytic disease of the newborn? [1]
Explain this test [1]
How do you treat DAT+ve babies [2]
Direct antiglobulin test (DAT)
- Get babys blood and mix with reagant with anti IgG antibodies. If babies blood cells are covered in maternal IgG then will clump
DAT +ve babies:
- Give folic acid supplementation for 6-8 weeks
- Follow up appointment to monitor for haemolytic anaemia
Why need to enquire about how well a baby is feeding if jaudiced? [2]
Stop feeding as well, so dehydration and weight loss is common
Describe how you measure bilirubin levels [2]
How do you interpret them? [+] Include when tx
TCB - Transcutaneous bilirubinometer:
- > 35 weeks gestation
- > 24 hrs old
Serum bilirubin
Interpretation:
- Plot total bilirubin
- If crosses phototherapy line, then tx
- If rises by > 8.5 / hr then treat
- Can stop treatment if 5 boxes below phototherapy threshold
- Check guideline
A neonate presents with jaundice. Which first line investigations would you perform? [3]
Which further ones might you consider? [2]
First line:
* Total bilirubin
* FBC
* Group and DAT
Consider:
- CRP and blood cultures
- Blood film and G6PD testing
When do you stop phototherapy treatment for jaundice? [1]
When bilirubin is below > 50 umol/L/ phototherapy line
- BUT: be careful of rebound bilirubin 12-18 hrs after
What is an important anatomical reason for jaundice? [1]
Biliary atresia:
* Intra +/- extra-hepatic bile duct atresia
