Paediatric Neonatology Flashcards
Neonatal resuscitation
- Dry the baby
- Keep baby warm - heat lamp/plastic bag
- APGAR Score
- Stimulate breathing - neutral position of head, check for aiway obstruction
- 5 inflation breaths
- 30 chest compressions, 2 inflation breaths
When to do APGAR scores
1, 5 and 10 minutes after birth
What does prolonged hypoxia cause
Hypoxic ischaemic encephalopathy
How to treat hypoxic ischaemic encephalopathy
Therapeutic hypothermia with active cooling
APGAR Score
Appearance - skin colour Pulse Grimmace - response to stimulation Activity - muscle tone Respiration
Delayed umbilical cord clamping
Uncompromised neonates - delay of at least 1 min before clamping
Neonates that require resus - clamp sooner
Benefits and disadvantages of delayed cord clamping
Advantages:
- increases neonatal haemoglobin and iron stores
- improves blood pressure
- decreases the incidence of intraventricular haemorrhage and necrotising enterocolitis
Disadvantages:
- neonatal jaundice increases
Care immediately after birth
Skin to skin Clamp the umbilical cord Dry the baby Keep baby warm with hat and blanket Vitamin K intramuscular injection Label the baby Measure weight and height
When to take oral vitamin K
Dose at birth, 7 days and 6 weeks
When to do a newborn examination
Within 72 hours after birth
Repeated at 6 - 8 weeks by GP
When is the blood spot test done?
Day 5 (latest day 8)
Results take 6 - 8 weeks to come back
Pre ductal and post ductal saturations
Pre ductal - right hand - receives blood from the right subclavian artery before the ductus arteriosus
Post ductal - foot - recieves blood from the descending aorta after the ductus arteriosus
3 questions to ask in the newborn examination
- Are they feeding
- FHx of heart, hip or eye problems
- Have they passed meconium
If a mother is posivtive for group B streptococcus, what is the management?
Prophylactic IV benzylpenicillin and gentamycin for neonate
Risk factors for neonatal sepsis
Vaginal GBS colonisation GBS sepsis in a previous child Maternal sepsis Chorioamnionitis Maternal fever of > 38 celsius Prematurity PROM
Clinical features of neonatal sepsis
Fever Reduced tone and activity Poor feeding Respiratory distress or apnoea Vomiting Hypoxia Jaundice within 24 hours Seizures Hypoglycaemia
Treatment for suspected neonatal sepsis
1 risk factor/ feature - monitor for at least 12 hours
2 + Risk factors/ features - antibiotics
1 red flag sign - antibiotics
Antibiotics for neonatal sepsis
Benzylpenicillin and gentamyin
Caput succeddaneum features - cause, suture lines, colour
- Caused by pressure to the scalp e.g. forceps delivery
- oedema outside the periosteum
- does cross the suture lines
- resolves within a few days
Cephalohaematoma features - cause, suture lines, colour
- collection of blood between the skull and the periosteum
- caused by damaged blood vessels due to trauma
- does NOT cross the suture lines
- discolouration to skin
Pathophysiology of Erbs Palsy
Injury to C5/C6 nerves in the brachial plexus often due to shoulder dystocia because of macrosomnia, instrumental delivery or trauma
Erbs palsy presentation
Weakness of shoulder abduction, external roation, arm flexion and finger extension - waiters tip
Management of erbs palsy
Function normally returns within a few months but may require neurosurgical input if persists
What is a fractured clavicle during delivery associated with?
Shoulder dystocia
Instrumental delivery
Trauma
Macrosomia
How does a fractured clavicle after delivery present?
Asymmetry
Lack of movement of arm on affected side
Pain and distress when moving affected arm
Investigations and management for a fractured clavicle during delivery
Ix: USS or Xray
Mx: conservative or immobilisation - usually heals well
Pathophysiology of hypoxic ischaemic encephalopathy
Occurs due to prolonged or severe hypoxia in neonates that causes ischaemia and brain damage
Complications of HIE
Cerebral palsy due to permanent damage
Death
Causes of HIE
Maternal shock
Intrapartum haemorrhage
Prolapsed cord
Nuchal cord
Presentation of mild HIE
pH < 7 on umbilical artery blood gas
Poor APGAR score
Poor feeding
Irritable
Hyper alert
Resolves within 24 hours
Presentation of moderate HIE
pH < 7 on umbilical artery blood gas
Poor APGAR score
Poor feeding Lethargic and hypotonic Seizures Weeks to resolve 40% develop cerebral palsu
Presentation of severe HIE
pH < 7 on umbilical artery blood gas
Poor APGAR score
Reduced consciousness
Apnoea
Flaccid and reduced or absent reflexes
50% mortality/ 90% cerebral palsy
Management of HIE
MDT
Supportive - resus, ventilation, nutrition
Seizures - therapeutic hypothermia (33 - 34 celsius) for 72 hours
Physiological jaundice
Occurs at 2 - 7 days
Fetal haemoglobin is more fragile
Neonatal liver is less well developed
Causes of neonatal jaundice - increased production
Haemolytic anaemia ABO incompatability Haemorrhage Cephalo - haematoma Polycythaemia Sepsis or DIC G6PD deficiency
Causes of neonatal jaundice - decreased excretion
Prematurity Breast milk jaundice Neonatal cholestasis Biliary atresia Gilbert syndrome Hypothyroidism
Jaundice within 24 hours
Always pathological
Common cause - sepsis, treat with antibiotics and phototherapy
Kernicterus
Accumulation of bilirubin in the basal ganglia which can cause brain damage, cerebral palsy, learning disabilities and deafness
Breast milk jaundice pathophysiology
Components of breast milk inhibit the ability of the liver to conjugate bilirubin
More likely to become dehydrated if not feedinf adequately which can lead to constipation - increasing the absorption of bilirubin in the intestines
Haemolytic disease of the newborn pathophysiology
Mother - rhesus negative - no rhesus antigens, has the rhesus antibodies
Baby - rhesus positive - rhesus antigens, no antibodies
Occurs in second pregnancy
Prolonged jaundice
More than 14 days - term baby
More than 21 days - premature baby
Causes of prolonged jaundice
Biliary atresia
Hypothyroidism
G6PD deficiency
Investigations for prolonged jaundice
Bloods - TFTs, FBC Blood film - polycythaemia Blood type testing Direct Coombs test - haemolysis Blood and urine cultures - sepsis G6PDehydrogenase levels - G6PD deficiency
Management of neonatal jaundice
Plot bilirubin levels on treatment threshold chart
If above the line, phototherapy is given or if extremely high, blood transfusion given
Prematurity
Less than 37 weeks of gestation at birth
Under 28 weeks - extremely preterm
28 - 32 weeks - very preterm
32 - 37 weeks - moderate to late preterm
Associations with prematurity
Maternal alcohol, smoking or drug use Social deprivation Over or underweight mother Maternal co-morbidities Twins FHx of prematurity
Managment of prematurity to delay birth
- prophylactic vaginal progesterone
- prophylactic cervical cerclage
USS result for women that are suspected to have preterm deliveries
Cervical length of 25mm or less before 24 weeks gestation - give prophylaxis to delay birth
Management to improve outcomes in preterm babies
Tocolysis - nifedipine to delay labour
Maternal corticosteroids - before 35 weeks gestation
IV magnesium sulphate - before 34 weeks gestation - protects brain
Delayed cord clamping
Problems with premature babies
Respiratory distress - inadequate amounts of surfactant
Hypothermia
Hypoglycaemia
Poor feeding - lack of suckling reflex
Apnoea
Neonatal jaundice - under developed liver
Intraventricular haemorrhage
Retinopathy of prematurity - blood vessels proliferating behind retina
Necrotising enterocolitis
Long term affects of prematurity
Chronic lung disease of prematurity Learning and behaviour difficulties Recurrent infections Hearing and visual impairment Cerebral palsy
Apnoea
Spontaneous cessation of breathing for more than 20 seconds or shorter periods with oxygen desaturation or bradycardia
Management of apnoea
Tactile stimulation - prompt baby to restart breathing
IV caffeine
Who does retinopathy of prematurity affect?
Typically babies born before 32 weeks gestation
Complications of retinopathy of prematurity
Scarring
Retinal detachment
Blindness
Retinopathy of prematurity pathophysiology
Retinal blood vessel development starts at 16 weeks and ends at 37 - 40 weeks.
Blood vessels grow from the centre to the outer area and stimulated by hypoxia
When retina are exposed to higher concentrations of oxygen in a preterm baby, blood vessels do not develop but when hypoxic again, produce excessive blood vessels - neurovascularisation and scar tissue
Zones of the retina
Zone 1 - optic nerve and macula
Zone 2 - zone 1 edge to ora serrata (pigmented border between the retina and the ciliary body
Zone 3 - outside the ora serrata
Who is screened for retinopathy of prematurity
Babies born before 32 weeks
Under 1.5kg
Screening for retinopathy of prematurity
Screening starts at:
30 - 31 weeks of gestation - if born before 27 weeks
4 - 5 weeks of age - if born more than 27 weeks
Occurs at least every 2 weeks until the blood vessels reach zone 3
Plus disease
Tortous vessels
Hazy vitreous humour
Treatment for retinopathy of prematurtiy
Transpupillary laser photocoagulation - stops and reverses neurovascularisation
2nd line - cryotherapy and injection of intravitreal VEGF inhibitors
Surgery for retinal detachment
Necrotising enterocolitis pathophysiology
Condition that affects premature neonates where part of the bowel becomes necrotic
Life threatening emergency as can lead to perforation, peritonitis and shock
Risk factors for NEC
- Very low birth weight or prematurity
- Formula feeds
- Respiratory distress and assisted ventilation
- Sepsis
- PDA and other congenital heart disease
Investigations for NEC
Bloods - FBC, CRP
Blood culture
Blood gas - metabolic acidosis
Abdo xray
Management of NEC
IV fluids
IV antibiotics
Nill by mouth - NGT or TPN
Surgical emergency
Withdrawals fom opiates, SSRIs and alcohol features
Present 3 hours - 3 days after birth
CNS: irritable, tremors and seizures
Respiratory: tachypnoea
Metabolic: poor feeding, regurgitation and vomiting, hypoglycaemia, loose stools
Management of withdrawals in neonates
Monitor in hospital for at least 3 days
Urine testing
Oral morphine - opiate withdrawal
Oral phenobarbitone - non opiate withdrawal
Congenital rubella syndrome maternal vaccinations
If planning to get pregnant - 2 doses of MMR vaccine, 3 months apart (live attenuated)
Pregnant women - vaccine after birth
Chickenpox exposure during pregnancy
If not immune, IV varicella immunoglobulins as prophylaxis within 10 days of exposure
Risk factors for sudden infant death
Prematurity
Low birth weight
Smoking during pregnancy
Male
How to minimise SIDS
- Put baby on back when not supervised and sleeping
- keep their head uncovered
- place feet at the foot of bed to prevent slipping down
- keep cot clear of toys and blankets
- avoid smoking
- avoid co sleeping
- Maintain room temperature
