Paediatrics - neonatology Flashcards
What score is used to assess the health of a baby immediately after birth?
APGAR
What does APGAR stand for?
- Activity (muscle tone)
- Pulse
- Grimace (reflex irritability)
- Appearance (skin colour)
- Resp rate
When is the APGAR score measured?
- 1 minute
- 5 minute
… after birth, at 10 min if low
What is APGAR scored out of and what is a good/ bad score?
- < 4 bad
- 5-6 ok
- 7< good
out of 10
What should all babies be given ASAP following birth?
Vitamin K IM injection
all babies born deficient
What checks should be done soon after birth (2)?
- NIPE
- Hearing test (ottoscoustic emission test)
How soon after birth should a NIPE be done?
Within 72 hours
What are some causes of respiratory distress in the newborn (5)?
- Respiratory distress syndrome = mc (in premature infants)
- Transient tachypnoea of the newborn = mc overall
- Meconium aspiration
- Sepsis/ pneumonia
- Pneumothorax
What is respiratory distress syndrome of prematurity?
Disease causing difficulty breathing due to inadequate surfactant production
What gestational age are babies born at risk of respiratory distress syndrome?
32 weeks or below
What is the pathophysiology of respiratory distress syndrome?
Inadequate surfactant –> high surface tension –> atelectasis (partial lung collapse –> inadequate gaseous exchange
What are the signs/ symptoms of RDS on oximetry and observation (3)?
- Hypoxia
- Hypercapnia
- Respiratory distress (accessory muscles, tachypnoea, intercostal recession, etc…)
How would RDS of prematurity appear on xray?
Ground glass appearance
How is RDS managed (3)?
- Antenatal steroids (mature lungs)
- Endotracheal surfactant
- O2/ CPAP/ intubation + ventilation (if severe)
What are some complications of RDS (3)?
- Pneumothorax
- Infection
- Chronic lung disease of prematurity (bronchopulmonary dysplasia)
amongst many other complications
What is the cause of bronchopulomary dysplasia/ chronic lung disease of prematurity?
Chronic high flow oxygen as a baby –> reperfusion injury
What are the signs/ symptoms of bronchopulmonary dysplasia/ chronic lung disease of prematurity (3)?
- Chronic respiratory distress
- Recurrent chest infections
- Poor feeding + FTT
What would a CXR show for those with BPD/CLDOP?
Widespread opacity
How is BPD/CLDOP treated (5)?
- Vitamin A
- Caffeine
- Corticosteroids (to mother)
- CPAP/ O2
- Palivizumab/ vaccinations
What is palivizumab?
Monoclonal antibody against RSV
What is transient tachypnoea of the newborn?
Residual pulmonary fluid remains in lung tissue after delivery –> tachypnoea + resp distress
What is a finding on x ray of those with transient tachypnoea of the newborn?
Fluid in the horizontal fissure
How is TTON treated (2)?
- O2 (if sats low)
- CPAP (if more severe)
What is the mechanism aspirated meconium occurs?
Meconium shat into amniotic fluid –> foetus inhales amniotic fluid –> irritates the lungs
What is a risk factor for aspirated meconium?
Post term
What are the signs/ symptoms of aspirated meconium(2)?
- Meconium stained amniotic fluid
- Resp distress Sx
What are the findings on x ray of those with aspirated meconium (2)?
- Consolidation
- Patchy atelectasis
How is aspirated meconium treated (3)?
- Suction
- O2
- Abx
What is a complication of aspirated meconium?
Persistent pulmonary hypertension of the newborn
mc cause of death following meconium aspiration
How is persistent pulmonary hypertension of the newborn treated (2)?
- Viagra
- NO2
What is a common breathing disorder in premature infants?
Apnoea of prematurity
should not happen in term infants
(3)How is apnoea of prematurity treated?
- Apnoea monitor
- Tactile stimulation
- IV caffeine
What is necrotising enterocolitis?
Death and inflammation (sometimes with infection) of bowel tissue for an unknown reason
When does NEC typically occur after birth?
2-4 weeks
What is the main group of neonates affected by NEC?
Premature babies
can occur in term infants however very rare
Other than prematurity what are some other risk factors for NEC (3)?
- Low birth weight
- Formular fed
- Indomethacin (decreases mesenteric blood flow)
What is indomethacin and what is it used for?
NSAID - used to close a PDA
What are the signs/ symptoms of NEC (5)?
- Abdo distension (erythematous taught skin)
- Bilious vomiting
- Absent bowel sounds
- Bloody stool
- Poor feeding
How is NEC investigated?
- FBC (thrombocytopenia, neutropenia)
- Blood cultures
- Abdo X-ray (supine, front on)
What would an abdominal x-ray show in those with NEC (3)?
- Pneumatosis intestinalis (gas in bowel)
- Pneumoperitoneum (gas in abdominal cavity)
- Dilated bowels, thickened walls
How is NEC managed (3)?
- IV fluids + total parenteral feed
- Abx
- Laparotomy (remove dead bowel)
What are some complications of NEC (4)?
- Perforation
- Sepsis/ DIC/ shock
- FTT
- Short bowel syndrome
Where is the most common site of oesophageal atresia?
Proximal oesophagus
What do more distal oesophageal atresia sometimes present as?
Tracheoesophageal fistula
What are some risk factors for oesophageal atresia (3)?
- Trisomes (esp downs)
- IVF
- VACTERAL association (a group of linked birth defects)
What are the VACTERAL defects (6)?
- Vertebral defects
- Anal atresia
- Cardiac defects
- Tracheoesophageal fistula
- Renal anomalies
- Limb abnormalities
What are the symptoms/ signs of oesophageal atresia (4)?
- Polyhydramnios (due to not being able to swallow amniotic fluid)
- Cough
- Choke
-
Cyanotic
the 3 Cs
How is oesophageal atresia diagnosed?
X-ray
unable to pass NG tube
How is oesophageal atresia treated?
Anastomosis surgery ASAP
What is the most common bowel atresia?
Duodenal atresia
Where does the atresia usually occur in the duodenum?
Just past the ampulla of vater
What are some risk factors for duodenal atresia (4)?
- Downs = 1/3rd cases
- VACTERAL
- IVF
- Annular pancreas
What is an annular pancreas?
Pancreas wraps around duodenum
How is duodenal atresia diagnosed (2)?
- Antenatal scan
- X-ray
What is the x-ray finding for those with duodenal atresia?
‘Double bubble’ sign
stomach and first part of duodenum filled with air, and separated by the pyloric sphincter
How is duodenal atresia managed (3)?
- NG decompression
- IV fluid
- Duodenoduodenostomy
What is jaundice?
Abnormally high levels of bilirubin
How is bilirubin usually excreted?
RBC –> unconjugated bilirubin –> conjugated bilirubin (in liver) –> excreted in bile/ urine
What are some causes of neonatal jaundice (6)?
- Physiological jaundice
- Sepsis (TORCH infections)
- HDN/ ABO incompatibility
- Biliary atresia
- Hypothyroidism
- CF
What timeframe is physiological jaundice normal/ expected?
- 24 hours –> 2 weeks
jaundice should not occur outside of this window
What causes of neonatal jaundice would present within 24 hours of birth (2)?
- Sepsis
- HDN/ ABO incompatibility
Why does physiological jaundice occur in the newborn (2)?
- Foetal haemoglobin breaks down faster than adult haemoglobin, therefore more bilirubin produced
- Baby no longer has access to placenta for excretion of bilirubin
When is jaundice prolonged in premature neonates?
After 21 days
Why is jaundice more likely in premature neonates?
They have an underdeveloped liver therefore cannot conjugate bilirubin as effectively
What is a risk factor for the development of physiological neonatal jaundice?
Being breast fed
for various reasons including components of breast milk that inhibit liver, more likely for baby to become dehydrated
How is neonatal jaundice investigated (4)?
- FBC, U&E, LFTs, TFT
- Bilirubin levels
- Maternal vs baby blood type
- Blood cultures (for sepsis)
investigate general causes of anaemia
How is neonatal jaundice managed (2)?
- Phototherapy
- Exchange transfusion (if severe)
How can bilirubin levels be monitored if neonatal jaundice is present?
Transcut bilirubin monitor
What is a complication of neonatal jaundice?
Kernicterus (build up of unconjugated bilirubin in the CNS)
What long term affects can Kernicterus have (3)?
- Deafness
- Cerebral palsy
- Learning disability
What is biliary atresia?
Bile duct either stenosed or absent
What are the symptoms of biliary atresia (4)?
- Prolonged jaundice
- Pale stool
- Dark urine
- Distended stomach
What blood finding would suggest biliary atresia?
High levels of conjugated bilirubin
How is biliary atresia treated?
Kasai portoenterostomy
section of small intestine attached to opening of liver
What are two conditions that cause the herniation of abdo contents outside the abdomen?
- Gastroschisis
- Exomphalus (omphalocele)
What defect is seen in gastroschisis vs exomphalus?
- Gastroschisis = bowel protrudes without peritoneal covering through abdominal wall (usually to the right of the umbilicus)
Gastroshitis = shit my pants because no peritoneal covering - Omphalocele = bowel protrudes through umbilicus covered by a layer of peritoneum
O for shape of umbilicus
Which type of abdominal content herniation seen in neonates is much more commonly associated with other congenital defects?
Omphalocele
How should gastroschisis be managed?
Immediate repair
How should exomphalus/ omphalocele be managed?
Usually staged repairs over 12 month period (depends on size)
How should foetuses with gastroschisis/ exomphalus be delivered?
C-section
What is neonatal hepatic syndrome?
Collection of disorders that cause liver dysfunction in newborns
What are some causes of neonatal hepatic syndrome (4)?
- Viral infections
- Metabolic disorders (galactosemia, A1AT deficiency)
- Biliary tract disorders (coledochal cyst, biliary atresia)
- Idiopathic
What is galactosemia?
Deficiency in enzymes that metabolise milk leading to a build up of galactose in the blood which can damage organs such as the liver
What are a group of infections that are problematic in pregnancy and can pass from the mother to foetus/ newborn (5)?
- Toxoplasmosis
- Other
- Rubella
- CMV
- HSV
What is a congenital infection?
Infection passed from mother to child during pregnancy
What are some general symptoms/ signs of congenital TORCH infections (5)?
- Neonatal jaundice
- Polyhydramnios
- Rash in newborn (blueberry muffin rash)
- Growth restriction
- Hepatosplenomegally
What are the ‘other’ organisms in the TORCH acronym infections (5)?
- Syphilis
- VZV
- Parovirus B19
- HIV
- Hep B
What are the risks to the foetus/ newborn associated with maternal toxoplasmosis infection (3)?
Classic triad
* Hydrocephalus
* Intracranial calcifications
* Chorioretinitis
also increases the risk of miscarriage
How is toxoplasmosis complications in the neonate investigated?
MRI shows intracranial calcifications
How is congenital toxoplasmosis treated (2)?
- Pyrimethamine
- Sulfadiazine
spiramycin for mother
What effects does congenital syphilis infection have on the newborn (4)?
- Deafness
- Changes to teeth (hutchinson incisors)
- Visual problems (interstitial keratitis)
- Rash
When is the baby most at risk of congenital syphilis?
New maternal infection in the last trimester of pregnancy
How is congenital syphilis treated?
IM benzathine benzylepenicilin
What are the symptoms of congenital rubella in an infant (4)?
- Deafness
- Cataracts
- Congenital heart disease (PDA, pulm stenosis)
- Learning disability
When is congenital rubella usually passed on?
First 20 weeks of pregnancy
What are the symptoms of congenital CMV (4)?
Vague Sx:
* Foetal growth restriction
* Microcephaly
* Hearing, vision loss
* Seizures
Do most maternal CMV infections result in congenital CMV?
No, it is usually not passed to foetus
How is CMV infection treated?
Ganciclovir
How is congenital HSV usually contracted?
Exposure to mothers genital lesions at time of delivery
What are the symptoms of congenital HSV (3)?
- Localised infection around skin/ mouth
- Encephalitis
- Disseminated infection
What ware the symptoms of HSV encephalitis (4)?
- Fever
- Headache
- Seizures
- Focal neurological defects
How should babies be delivered if the mother has HSV?
C-section
if there are active lesions
How is congenital HSV treated?
Aciclovir
What are risks associated with VZV infection during pregnancy (3)?
- More severe infection in mother
- Foetal varicella syndrome
- Neonatal varicella infection
What are the options for treating VZV in pregnancy (2)?
- Aciclovir if > 20 weeks
- VZ Igs
What is a symptom of congenital VZV infection?
Limb hypoplasia
What are the two types of neonatal sepsis in terms of when symptoms appear?
- Early onset (<72 hours)
- Late onset (>72 hours)
What is the most common cause of early onset neonatal sepsis?
Group B strep (strep agalactiae)
What are some other causes of early onset neonatal sepsis not including GBS (2)?
- E. coli
- Listeria monocytogenes
What are the symptoms of GBS sepsis in a neonate (5)?
- !!!Respiratory distress!!!
- Poor feeding
- Fever
- Reduced tone
- Reduced urine output
What does neonatal sepsis often present as/ start as before becoming sepsis?
Neonatal meningitis
Where does GBS usually live/ reside?
In the GI tract/ vagina
so neonate is infected during birth
How is early onset neonatal sepsis treated - which Abx (2)?
- Benzylpenicilln
- Gentamycin
What are some risk factors for neonatal sepsis (4)?
- Vaginal GBS colonisation
- Prematurity/ low birth weight
- Prolonged rupture of membranes
- Maternal sepsis
How should neonatal sepsis be investigated (4)?
- FBC, CRP
- Blood cultures
- LP
- VBG = metabolic acidosis due to tissue hypoxia and anaerobic metabolism
neonatal sepsis can also lead to resp acidosis or mixed acidosis if resp failure occurs
How can neonatal sepsis be prevented in mothers who’s vaginal swabs are positive for GBS?
Intrapartum IV benzylpenicilin
What is the ongoing management of neonatal sepsis (2)?
- Check CRP at 24 hours and blood cultures at 36 hours if negative stop antibiotics
- Check CRP and blood cultures again at 5 days if still on treatment
What causes listeria infections in mothers/ newborns?
Unpasteurised dairy products, meats
Blue cheese
What are 2 causes of late onset neonatal sepsis?
- Staph epidermidis (coagulase negative staphylococcal species)
- Staph aureus
bacteria from surrounding hospital environment
What is cleft lip/ palate?
A congenital split/ open section of upper lip/ palate (soft or hard)
What percentage of defects are cleft lip, what percentage are cleft palate, what are both?
- Lip = 40%
- Palate = 15%
- Both = 45%
How is cleft lip and cleft palate treated?
- Cleft lip = surgical correction at 3 months
- Cleft palate = surgical correction at 6-12 months
What conditions can having cleft lip/ palate put you at higher risk of developing later in life (2)?
- Glue ear/ ear infection
- Hearing problems
What are babies with cleft lip/ palate at risk of and how can this be mitigated against?
Difficulties eating/ drinking
babies can use specially shaped bottles/ teats
What is cleft lip/ palate associated with?
Other congenital defects affecting facial development (Pierre robins, treacher collins) + pataus + DiGeorge
often occur spontaneously on its own however
What is neonatal hypoglycaemia?
Low blood sugar in neonates usually considered < 2.6mmol/l
When is neonatal hypoglycaemia most common?
First 24 hours of life
What are the symptoms of neonatal hypoglycaemia (6)?
- Jittery
- Floppy
- Drowsy
- Poor feeding
- Tachypnoea
- Hypothermia
How is neonatal hypoglycaemia treated (2)?
- Asymptomatic + > 2 mmol/l = encourage feeding
- Symptomatic OR < 2 mmol/l = IV 10% dextrose
What are some risk factors for neonatal hypoglycaemia (4)?
- Preterm
- Maternal diabetes
- IUGR
- Sepsis
What is hypoxic ischemic encephalopathy?
Hypoxia + ischemia to the brain at/ around the time of birth
What is the pathophysiology of HIE (2)?
- Ischemia causes damage to the brain
- Reperfusion after ischemia causes a repercussion injury causing even more damage
What causes HIE (4)?
- Maternal shock
- Intrapartum haemorrhage
- Prolapsed cord
- Nuchal cord
What is a nuchal cord?
Cord around babys neck
What criteria are used to stage HIE into mild, moderate or severe?
Sarnat criteria
What are the mild symptoms of HIE (3)?
- Poor feeding
- Irritable
- Hyper-alert
What are the moderate symptoms of HIE (3)?
- Lethargic
- Hypotonic
- Seizures
What are the severe symptoms of HIE (3)?
- Reduced consciousness
- Apnoeas
- Reduced/ absent reflexes
What are some complications of HIE (4)?
- Intraventricular haemorrhage
- Cerebral palsy
- Development delay
- Epilepsy
How is HIE investigated (3)?
- ABG
- Glucose
- USS/ MRI head
in children at risk/ suspected HIE
How is HIE managed (3)?
- ABCDE
- Supportive care
- Therapeutic hypothermia
What is therapeutic hypothermia?
Neonates with HIE can have their body temp cooled to reduce the risk of damage from hypoxia
When is alcohol consumption in pregnancy the most damaging?
First 3 months
What are some effects of alcohol consumption on early pregnancy (3)?
- Miscarriage
- Small for dates
- Preterm delivery
What is it known as when babies of mothers who have drunk display certain characteristics?
Fetal alcohol syndrome
What are the signs/ symptoms of fatal alcohol syndrome (6)?
- Thin upper lip
- Microcephaly
- Smooth flat philtum (groove between nose and lip)
- Small eyes
- CP/ learning disability
- Hearing/ visual problems
What is neonatal abstinence syndrome?
Withdrawal symptoms that happen in neonates who’s mothers used substances
What are the signs/ symptoms of neonatal abstinence syndrome (6)?
- Irritability
- Increased tone
- Sweating/ poor temperature control
- Tachypnoea
- Poor feeding
- Vomiting
How can neonatal abstinence syndrome be managed (2)?
- Opiate withdrawal = morphine sulphate
- Other substances = phenobarbitone
SSRI withdrawal does not need to be treated
What condition can affect the vision of babies born prematurely?
Retinopathy of prematurity
What is the pathophysiology of retinopathy of prematurity?
Hypoxic womb environment –> retinal blood vessel development –> in premature baby, retina exposed to high oxygen environment (supplemental O2) –> no stimulant for BV development –> when hypoxic environment recurs –> excessive BVs + scar tissue formation
What are 2 risk factors for ROP?
- Low birth weight
- Prematurity
How is retinopathy of prematurity picked up?
All babies under 32 weeks or under 1.5 kg should be screened every 2 weeks for ROP
How is ROP treated?
Laser eye surgery (transpupillary laser photocoagulation)
holts and reverses nerovascularisation
What are two injuries that may occur to the scalp during delivery?
- Caput succedaneum
- Cephalohaematoma
What is caput succedaneum vs cephalohaematoma?
- Caput succedaneum = oedema outside the periosteum
- Cephalohaematoma = blood collecting under the periosteum
What is the periosteum?
Membranous lining of the bone
How can caput succedaneum and cephalohaematoma be distinguished upon examination?
- Caput succedaneum crosses the suture lines of the head
- Cephalohaematoma does not cross the suture lines of the head (well demarcated)
this is because the periosteum connects to the bone at the suture lines preventing the blood from spreading out
What nerves are sometimes injured during delivery (2)?
- Facial nerve
- Brachial plexus (C5/6)
What is a risk factor for facial nerve paralysis associated with delivery?
Forceps delivery
What does damage to the facial nerve present as?
Weakness on one side
usually resolves on its own, otherwise will need neurosurgical input
What is damage to the brachial plexus (C5/6) during delivery known as?
Erbs palsy
What are some risk factors for Erbs palsy (2)?
- Shoulder dystocia
- Traumatic/ instrumental delivery
What position would a baby with Erbs palsy be in?
- Internally rooted shoulder
- Extended elbow
- Flexed wrist facing backwards
Waiters Tip
What injury during delivery may be associated with asymmetry/ lack of movement of an arm?
Clavicle fracture
What are the signs/ symptoms/ features of non accidental injury (4)?
- Multiple bruises in non-mobile child (esp tummy/ thighs)
- Anal fissures
- Recurrent UTIs
- Delayed presentation
Who should be notified if NAI suspected?
Child protection services/ social services
What act allows a child to talk to doctor without guardian in room?
Child act 2004
How is NAI investigated (3)?
- FBC
- Clotting screen
- Full body X-ray
What are some differentials for a non accidental injury (2)?
- Bleeding disorders
- ITP
What effects can maternal hyperthyroidism have on the baby (4)?
- Low birth weight
- Preterm
- Neonatal hyperthyroidism (if TSH receptor antibodies cross placenta)
- Tachycardia
What are the effects of gestational diabetes on the baby (5)?
- Macrosomia
- Neonatal hypoglycaemia
- RDS
- Prematurity
- Increased risk of diabetes later in life
What is it known as when babys suddenly die for an unexplained reason?
Sudden infant death syndrome
What are some risk factors for sudden infant death syndrome (5)?
- Prematurity
- Low birth weight
- Smoking in house + during pregnancy
- Male
- Prone sleeping
How can the risk of sudden infant death syndrome be reduced (4)?
- Lie baby on its back
- Keep the babys head uncovered
- Don’t smoke
- Don’t sleep in same bed
