Paediatrics Neonatology Flashcards
What is surface tension?
Attraction of the molecules in a liquid to each other
What are alveoli?
Small sacs where gas collects and diffuses into the blood during inhalation - lined with fluid (these molecules pull together due to surface tension - attempting to collapse the space in alveoli)
What is surfactant?
Fluid produced by type II alveolar cells containing proteins and fats - reduces surface tension of the fluid in the lungs
What is the result of surfactant?
Maximises surface area of the alveoli
Reduces force needed to expand alveoli
Thus surfactant increases lung compliance
When do type II alveolar cells start producing surfactant?
Between 24 and 34 weeks gestation
What helps clear fluid from the lungs at birth?
Thorax is squeezed as it passes through vagina
What is relseased by the neonate in response to the stress of labour?
Adrenalin and cortisol (stimulates respiratory effort)
Why does the foramen ovale close at birth? What does it become?
First breath expands alveoli - decreased pulmonary vascular resistance causing fall in pressure in the right atrium
Left atrial pressure is now higher than gith which causes closure of foramen ovale - this becomes the fossa ovalis
Why does the ductus arteriosus close at birth?
Prostaglandins required to keep ductus arteriosus open and increased blood oxygen cause these to drop - resulting in closure of the ductus arteriosus which becomes the ligamentum arteriosum
Why does the ductus venosus stop functioning after birth?
Umbilical cord is clamped and there is no blood flow in the umbilical veins - this structurally closes and becomes the ligamentum venosum
What is the result of hypoxia during labour and birth?
Bradycardia
Reduced consciousness
Drop in respiratory effort
Extended hypoxia = hypoxic-ischaemic encephalopathy (HIE) - potentially cerebral palsy
What are some issues in neonatal resuscitation?
Babies have large surface area to weight ratio (get cold easily)
Babies are born wet so lose heat rapidly
Babies which are born through meconium may have it in mouth / airway
What are the principles of neonatal resuscitation?
Warm baby
Calculate APGAR score
Stimulate breathing
Inflation breaths
Chest compressions
How to warm the baby?
Get baby dry (vigorous drying helps stimulate breathing)
Keep warm under heat lamp
Babies under 28 weeks are placed in a plastic bag whilst wet and managed under heat lamp
When and how is the APGAR score calculated?
1, 5 and 20 minutes whilst resuscitation continues (used as an indicator of progress)
Lowest score is 0 and highest is 10
How to stimulate the baby to breath?
Vigorous drying
Place head in neutral position to keep airway open (towel under shoulders can help)
If gasping then check for airway obstruction (meconium) and consider aspiration
When are inflation breaths given?
When neonate is gasping or not breathing despite adequate initial stimulation
How are inflation breaths given?
2 cycles of 5 inflation breaths (lasting 3 seconds)
If no response then 30 seconds of ventilation breaths
In no response then chest compressions (coordinated with ventilation breaths)
What should be used when performing inflation breaths in term/near term babies or pre-term babies?
Term = Air
Pre-term = air and oxygen (aim for gradual rise in sats not exceeding 95%)
How to perform chest compressions?
Start chest compressions if heart rate below 60bpm despite resus and inflation breaths
Performed at 3:1 ratio with ventilation breaths
What should be given in severe situations during neonatal resus?
IV drugs and intubation
What may babies with hypoxic-ischaemic encephalopathy (HIE) benefit from?
Therapeutic hypothermia with active cooling (must have gestational age >= 36 weeks and weight greater than 1800g)
Outline A-E assessment in a child?
Assessments
Airway and breathing = effort of breathing, RR and rhythm, stridor and wheeze, auscultation, skin colour
Breathing = HR, BP, cap refil, skin temp
Disability = Conscious, pupils, BM
Exposure = fever, rash, brusing
Interventions
Airway =
- “head tilt chin lift” (neutral in infant, sniffing in child)
- Naso-pharyngeal airways
Breathing =
- High flow oxygen (15 litres / min) - oxygen mask with reservoir bag
- Intubation and ventilation
Circulation =
- 20ml/kg bolus of 0.9% sodium chloride (in DKA 1-ml/kg due to risk of cerebral oedema)
Disability =
- AVPU (alert, voice, pain, unresponsive)
- If P or U consider intuvation
- Hypoglycaemia = 2ml/kg 10% glucose IV or IO followed by glucose infusion
Complete the following table:
What is placental transfusion?
Blood from the umbilical cord entering the circulation of the body
What are the benefits of delayed cord clamping?
Improved haemoglobin
Iron stores
Blood pressure
Reduction in intraventricular haemorrhage
Reduction in necrotising enterocolitis
What is an apparent negative effect of delayed cord clamping?
Neonatal jaundice (requiring more phototherapy)
How long should the delay in cord clamping be?
1 minute (clamped sppner in those that need resus)
What is the care for neonates immediately after birth?
Skin to skin
Clamp umbilical cord
Dry baby
Keep warm in hat and blankets
Vit K
Label baby
Measure weight and length
Why and how are babies given vitamin K?
Babies are deficient
IM injection in the thigh
Why is vitamin K given after birth?
Prevents bleeding: intracranial, from umbilical stump and GI bleeding
How else may vitamin K be given?
Orally - longer to act and requires doses at birth, 7 days and 6 weeks
Why is skin to skin contact important?
Helps warm baby
Improves mother and baby interaction
Calms baby
Improves breast feeding
What forms part of management once mum and baby are out of delivery room?
Initiate breast / bottle feeding when baby is alert enough
First bath (can wait days if needed)
Newborn examination within 72 hours
Blood spot test
Newborn hearing test
When is the blood spot screening test performed on newborns?
Day 5 or 8 at latest after consent from parent
What does the blood spoot screening test look for?
9 congenital conditions:
Sickle cell disease
Cystic fibrosis
Congenital hypothyroidism
Phenylketonuria
Medium-chain acyl-CoA dehydrogenase deficiency (MCADD)
Maple syrup urine disease (MSUD)
Isovaleric acidaemia (IVA)
Glutaric aciduria type 1 (GA1)
Homocystin
How long do results from the blood spot screening test take to come back?
6-8 weeks
When is a newborn examination performed?
72 hours after birth and repeated at 6-8 weeks
What are the principles of the newborn examination?
Wash hands before and after
Explain and reassure to parents
Keep baby warm
Start from head and work to toes
Ask:
- Has the baby passed meconium
- Is the baby feeding ok?
- FH of congenital heart, eye or hip problems
How to measure oxygen saturations in newborn examination?
Pre-ductal and post-ductal oxygen sats checked (before and after ductus arteriosus)
Normal sats are >96% (with difference of no more than 2% - if abnormal then potential admission)
Where is the ductus arteriosus and what is its function?
Arch of the aorta (connects aorta with pulmonary artery)
Normally stops functioning after 1-3 days of birth
Allows blood from deoxygenated right side of the circulation to mix with oxygenated left sided circulation
Why is the ductus arteriosus important?
Certain heart conditions are duct-dependent meaning they rely on the mixing of blood across the ductus arteriosus - when it closes there can be rapid deterioration of symptoms
Where are pre-ductal saturations measured?
Babies right hand (this recieves blood from the right subclavian artery a branch of the brachiocephalic artery which branches from the aorta before the ductus arteriosus
Where are post-ductal saturations measured?
Either foot (these recieve blood from the descending aorta - occuring after the ductus arteriosus)
What to look for in the general appearance of a neonate?
Colour (pink is good)
Tone
Cry
What should be looked for on the head examination of a newborn?
General appearance: size, shape, dysmorphology, caput succedaneum, cephalohaematoma, and any facial injury
Head circumference (occipital frontal circumference - OCP)
Anterior and posterior fontanelles
Sutures: overlapping sutures are common and usually resolve as the baby grows
Ears: skin tags, low set ears, asymmetry
Eyes: slight squits are normal, epicanthic folds can indicate Down’s, purulent discharge = infection
Red reflex: using an opthalmoscope - check for symmetry (more pale in dark skinned babies) - absent in congenital cataracts and retinoblastoma
Mouth - cleft lip or tongue tie
Put little finger in mouth to check suckling reflect and feel the palate for cleft palate
What to examine on a newborns shoulders and arms?
Shoulder symmetry: check for clavicle fracture
Arm movement: check for Erbs palsy
Brachial pulses
Radial pulses
Palmar creases: single crease = Down’s but may be normal
Digits: check number and if they are straight or curved (clinodactyly)
Use a sats probe on the right wrist for pre-ductal reading
What to examine on chest of a newborn baby?
Oxygen sats - right wrist and feet - above 95% is normal
Observe breathing - respiratory distress, symmetry and listen for stridor
Heart sounds - look for murmurs, heart sounds, HR and identify which side the heart is on
Breath sounds - listen for symmetry, good air entry and added sounds
What to look for in the abdomen on a newborn examination?
Observe the shape: concave may be diaphragmatic hernia with abdo contents in chest
Umbilical stump: look for discharge, infection and periumbilical hernia
Palpate: for organomegaly, hernias or masses
What to look for in the genitals in a newborn examination?
Observe for the sex, ambiguity and obvious abnormalities
Palpate testes and scrotum - check both present and descended, check for hernias / hydrocoeles
Inspect penis for hypospadias, epispadias and urination
Inspect anus to check its patent
Ask about meconium and whether baby has opened bowels
What to look for in the legs for a newborn examination?
Observe legs and hips for equal movements, skin creases, tone and talipes
Barlows and ortolani manoeuvres for clunking, clicking and dislocation of the hips
Count the toes
What to look for in the back for a newborn examination?
Inspect and palpate the spine for curvature, spina bifida and pilonidal sinus
What to look for on reflexes for newborn examination?
Moro reflex: rapidly tipped back then arms and legs will extend
Suckling reflex
Rooting reflex: ticking cheek causes them to turn to stimulus
Grasp reflex: place a finger in palm causes grasp
Stepping reflex: when held upright and feet touch a surface they make a stepping motion
What to look for on skin on newborn examination?
Haemangiomas
Port wine stains
Mongolian blue spot
Cradle cap
Desquamation
Erythema toxicum
Milia
Acne
Naevus simplex (“stork bite”)
Moles
Transient pustular melanosis
What are talipes?
Clubfoot = ankle is in a supinated position rolled inwards (can be positional or structural)
What is the difference between positional and structural talipes?
Positional = muscles are tights, bones unaffected - foot can move into normal position (requires physio)
Structural = involves bones and requires referral to orthopaedic surgeon
Do skin findings on newborn examination require action?
No - many will fade with time
Do haemangiomas on newborns require treatment?
Only when near the eyes, mouth or affecting the airway - requires treatment with beta blockers i.e. propanolol (otherwise monitor and usually resolve with time)
What are port wine stains?
Pink patches of skin, often on the face, caused by abnormalities affecting the capillaries - don’t fade with time and turn a darker red / purple colour
What can port wine stains be related to?
Sturge-Weber syndrome with visual impairment, learning difficulties, headaches, epilepsy and glaucoma
What is the management of clunky / clicky hips?
Referral for a hip ultrasound to rule out developmental dysplasia of the hips
What do cephalohaematomas require monitoring for?
Jaundice and anaemia
What do bony injuries in newborn examination require?
X-ray to look for fractures (e.g. clavicular fracture)
How to manage soft systolic murmurs in newborns?
Grade 2 or less require monitoring as these often resolve after 24 or 48 hours (may be caused by a patent foramen ovale which closes shortly after birth)
How to manage suspicion of heart failure / congenital heart disease?
Referral to cardiology for an ECG and echocardiogram
If unwell then admit to neonatal unit and immediate management
How to complete a newborn examination?
Discuss abnormalities with a senior
Action any abnormalities (e.g. ultrasound request for clicks hips)
Document the examination findings on the newborn and infant physical examination (NIPE) and in the baby’s red book
Explain, reassure and answer any questions with the parents
Arrange referrals and followup if required
What is caput succedaneum?
Oedema collecting in the scalp outside of the periosteum caused by pressure to a specific area of the scalp during prolonged or instrumental delivery
What is the periosteum?
Layer of dense connective tissue outside the skin (doesnt cross the sutures)
Does caput succedaneum require any treatment?
No treatment and resolves in a few days
What is a cephalohaematoma?
Collection of blood between the periosteum and the skull
When does a cephalohaematoma occur?
Traumatic, prolonged or instrumental delivery (described as traumatic subperiosteal haematoma)
Why does the blood not cross the suture line in cephalohaematoma?
Blood is below the periosteum
What is the management of cephalohaematoma?
No intervention and resolves in a few months
Monitored for anaemia and jaundice due to blood which collects in the haematoma (breaking down to bilirubin)
When can facial paralysis occur in childbirth?
During forceps delivery - function normally returns spontaneously in a few months - if not then neurosurgical input required
When can Erb’s palsy occur in childbirth?
Injury to the C5/C6 nerves in the brachial plexus
What is Erb’s palsy associated with?
Shoulder dystocia
Traumatic / instrumental delivery
Large birth weight
What does damaged C5/C6 nerves present as?
Weakness of:
Shoulder abduction
External rotation
Arm flexion
Finger extension
Leaving arm having a “waiters tip”
What is the treatment of Erb’s palsy after birth?
Function normally returns spontaneously within a few month (if not then require neurosurgical input)
What is a fractured clavicle during childbirth associated with?
Shoulder dystocia
Traumatic delivery
Instrumental delivery
Large birth weight
How can a fractured clavicle be picked up on during newborn examination?
Noticable lack of movement / asymmetry
Asymmetry of the shoulders with affected shoulder lower than normal
Pain on movement of the arm
How can a fractured clavicle be confirmed?
Ultrasound / X-ray
What is the management of a fractured clavicle?
Conservative with immobilisation of the affected arm
What is the main complication of a fractured clavicle?
Injury to the brachial plexus with a subsequent nerve palsy
What organisms commonly cause neonatal sepsis?
Group B streptococcus (GBS)
Escherichia coli (e. coli)
Listeria
Klebsiella
Staphylococcus aureus
What are the risk factors of neonatal sepsis?
Vaginal GBS colonisation
GBS sepsis in a previous baby
Maternal sepsis, chorioamnionitis or fever > 38C
Prematurity (less than 37 weeks)
Early (premature) rupture of membrane
Prolonged rupture of membrane (PROM)
What are the clinical features of neonatal sepsis?
Fever
Reduced tone and activity
Poor feeding
Respiratory distress or apnoea
Vomiting
Tachycardia or bradycardia
Hypoxia
Jaundice within 24 hours
Seizures
Hypoglycaemia
What are the red flags of neonatal sepsis?
Suspected sepsis in 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
What is the management of neonatal sepsis?
If one risk factor / clinical features then observe for 12 hours
If two or more risk factors / clinical features then start abx
Abx if single red flag (within 1 hour of decision)
Blood cultures should be taken before
Check baseline FBC and CRP
Lumbar puncture if features of meningitis (e.g. seizures)
What are the antibiotic choice in neonatal sepsis?
Benzylpenicillin and gentamycin as first line
3rd gen cephalosporin (e.g. cefotaxime) may be given as alternative in lower risk babies
What is the ongoing management of neonatal sepsis?
Check CRP again at 24 hours and check blood culture results at 36 hours
STOP treatment IF clinically well, blood cultures are negative 36 hours after taking them and both CRP are less than 10
Check CRP after 5 days if still on treatment and stop if: clinically well, lumbar puncture and blood culturesare negative and CRP has returned to normal
When to consider a lumbar puncture in neonatal sepsis?
Any of CRP results are more than 10
When does hypoxic ischaemic encephalopathy occur?
In neonates as a result of hypoxia during birth
What can result from HIE?
Cerebral palsy
When to suspect HIE?
Events which could lead to hypoxia
Acidosis (pH<7) on the umbilical artery blood gas
Poor Apgar scores
Features of mild/moderate or severe HIE or evidence of multi organ failure
What are some causes of HIE?
Maternal shock
Intrapartum haemorrhage
Prolapsed cord
Nuchal cord (cord is wrapped around the neck of the baby)
What is the Sarnat staging system for HIE?
What is the management of HIE?
Coordinated by specialists in neonatology
Supportive - resus, ventilation, circulatory support, nutrition, acid base balance and treatment of seizures
Therapeutic hypothermia - is a option to help protect brain from hypoxic injury
Follow up from paediatrician and multidisciplinary team - for assessing development
How does therapeutic hypothermia work?
In neonatal ICU baby is actively cooled with cooling blankets and cooling hat - target temp of 33 and 34C measured with rectal probe - continued for 72 hours after baby is warmed to normal temp over 6 hours
Intention is to reduce inglammation and neurone loss after the acute hypoxic injury
Reduces risk of cerebral palsy, developmental delay, learning disability, blindness and death
How is conjugated bilirubin excreted?
Via the biliary system into GI tract and via the urine
Why does physiological jaundice happen?
High conc of RBCs in fetus and neonate (these are fragile)
Normally bilirubin is excreted via the placenta - thus at birth there is a risk in bilirubin causing yellow skin for 2-7 days (normally resolves by 10 days)
The fetus also have less developed liver function at birth
What are the causes of neonatal jaundice (increased production of bilirubin or decreased clearance of bilirubin)
Increased production:
- Haemolytic disease of the newborn
- ABO incompatibility
- Haemorrhage
- Intraventricular haemorrhage
- Cephalo-haematoma
- Polycythaemia
- Sepsis and DIC
- G6PD deficiency
Decreased clearance:
- Prematurity
- Breast milk jaundice
- Neonatal cholestasis
- Extrahepatic biliary atresia
- Endocrine disorders (hypothyroid and hypopituitary)
- Gilbert syndrome
What is jaundice in the first 24 hours of life?
Pathological - urgent investiation - neonatal sepsis is a common cause
Why is jaundice in premature neonates more concerning?
Due to immature liver there may be more bilirubin increasing risk of kernicterus which is brain damage due to high bilirubin levels
Why are babies that are breast fed 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
- Inadequate breastfeeding may lead to slow passage of stools increasing absorption of bilirubin in the intestines
What is haemolytic disease of the newborn?
Cause of haemolysis and jaundice in the neonate
Caused by incompatibility between rhesus antigens on the surface of the RBCs of the mother and fetus
How does haemolytic disease of the newborn occur?
Woman who is rhesus D negative gives birth to a rhesus D positive baby and is exposed to fetal blood (becomes sensitized) - woman then develops antibodies to the rhesus D antigen - when the woman becomes pregnant again the mothers anti-D antibodies can cross the placenta causing haemolysis, anaemia and high bilirubin levels
What is prolonged jaundice?
More than 14 days in full term babies
More than 21 days in premature babies
What can cause prolonged jaundice?
Biliary atresia
Hypothyroidism
G6PD deficiency
What are the investigations for neonatal jaundice?
FBC and blood film for polycythaemia or anaemia
Conjugated bilirubin - elevated levels indicates a hepatobiliary cause
Blood type testing of mother and baby for ABO or rhesus incompatibility
Direct Coombs test (direct antiglobulin test) for haemolysis
Thyroid function particularly for hypothyroid
Blood and urine cultures if infection is suspected (suspected sepsis needs treatment with abx)
Glucose-6-phosphate-dehydrogenase (GDPD) levels for G6PD deficiency
What is the management of jaundiced neonates?
Total bilirubin levels are monitored and plotted on treatment threshold charts (specific for gestational age of baby) - if bilirubin levels exceed threshold levels then need to be commenced on treatment
What are the treatment options for neonatal jaundice?
Phototherapy
Exchange transfusion (for extremely high levels) - removing blood from neonate and replacing with donor blood
How is phototherapy used to treat neonatal jaundice?
Converts unconjugated bilirubin into isomers which can be excreted in the bile and urine without requiring conjugation in the liver
Baby is placed into a light box which shines UV light - with only nappy and eye patches on
Rebound bilirubin taken 12-18 hours after stopping
How does Kernicterus (a type of brain damage) occur?
Excessive bilirubin levels can cause damage to the CNS (as it can cross the blood-brain barrier)
What can kernicterus cause?
Cerebral palsy
Learning disability
Deafness
What is prematurity?
Birth before 37 weeks
When should resuscutation be carefully considered?
Under 500 grams and before 24 weeks
What are prematurity levels?
Extreme preterm = under 28 weeks
Very preterm = 28-32 weeks
Moderate to late preterm = 32-37 weeks
What are some association with prematurity?
Social deprivation
Smoking
Alcohol
Drugs
Overweight or underweight mother
Maternal co-morbidities
Twins
Personal or family history of prematurity
When should delaying birth be considered?
Women with a history of preterm birth
Ultrasound demonstrating a cervical length of 25mm or less before 24 weeks gestation
How can birth be delayed?
Prophylactic vaginal progesterone (progesterone suppository in the vagina)
Prophylactic cervical cerclage (putting a suture in the cervix to hold it closed)
What methods to improve the outcome in preterm labour?
Tocolysis with nifedipine (a CCB which suppresses labour)
Maternal corticosteroids (before 35 weeks gestation to reduce neonatal morbidity and mortality)
IV magnesium sulphate (offered before 34 weeks gestation and helps protect the baby’s brain)
Delayed cord clamping or milking to increase circulating blood volume and haemoglobin in the baby
What issues in early life does prematurity cause?
Respiratory distress syndrome
Hypothermia
Hypoglycaemia
Poor feeding
Apnoea and bradycardia
Neonatal jaundice
Intraventricular haemorrhage
Retinopathy of prematurity
Necrotising enterocolitis
Immature immune system and infection
What are the long term effects of prematurity?
Chronic lung disease of prematurity (CLDP)
Learning and behavioural difficulties
Susceptibility to infections, particularly respiratory tract infections
Hearing and visual impairment
Cerebral palsy
What are apnoeas?
Defined as periods when breathing stops spontaneously for more than 20 seconds or shorter periods with oxygen desaturation or bradycardia
When are apnoeas most common?
Premature neonates - all babies less than 28 weeks gestation
What is the cause of apnoeas?
Immaturity of the autonomic nervous system which controls respiration and heart rate
What are the causes of apnoeas?
Infection
Anaemia
Airway obstruction (may be positional)
CNS pathology, such as seizures or haemorrhage
Gastro-oesophageal reflux
Neonatal abstinence syndrome
What is the management of apnoeas?
- Attach apnoea monitor (make a sound when apnoea is occuring)
- Tactile stimulation to prompt rebreathing
- IV caffeine to prevent apnoea and bradycardia
- Episodes will settle with time
Who does retinopathy of prematurity affect?
Preterm (before 32 weeks)
Low birth weight
What can abnormal development of blood vessels in the retina cause?
Scarring
Retinal detachment
Blindness (treatment can prevent this - screening is important)
When is retinal blood vessel development?
From 16 to 37/40 weeks (grow from middle of retina outwards)
What is retinal vessel formation stimulated by?
Hypoxia - normal condition in the retina (in preterm babies this stimulant is removed)
What happens when hypoxia returns in retina of preterm?
Response of excessive blood vessels (neovascularisation) as well as scar tissue - can cause retinal detachment
What are the three zones of the retina?
Zone 1 = optic nerve + macula
Zone 2 = the edge of zone 1 to the ora serrata, the pigmented boarder between the retina and ciliary body
Zone 3 = outside the ora serrata
How are the retinal areas described?
Clock face = disease from 3 o’clock to 5 o’clock
How are the areas of disease in retinopathy of prematurity described?
Stage 1 (slightly abnormal vessel growth) to stage 5 (complete retinal detachment)
What is “plus disease” on retinopathy of prematurity?
Additional findings such as tortuous vessels and hazy vitreous humour
Which babies should be screened for ROP?
Born before 32 weeks or under 1.5kg
When should screening for ROP be performed?
30 – 31 weeks gestational age in babies born before 27 weeks
4 – 5 weeks of age in babies born after 27 weeks
How often should screening for ROP occur?
Every 2 weeks and cease when retinal vessels enter zone 3 (usually around 36 weeks gestation)
What is the treatment of ROP?
Stop new blood vessels developing:
- First line transpupillary laser photocoagulation to hald and reverse neovascularisation
- Cyrotherapy and injections of intravitreal VEGF inhibitors
- Surgery if retinal detachment occurs
Who does respiratory distress syndrome affect?
Premature neonates - born before the lungs start producing adequate surfactant (usually below 32 weeks)
What does an X-ray show for respiratory distress syndrome?
Ground glass appearance
What is the pathophysiology in respiratory distress syndrome?
Inadequate surfactant causing high surface tension in alveoli resulting in hypoxia, hypercapnia (high CO2) and respiratory distress
What is the prevention of respiratory distress syndrome?
Antenatal steriods (i.e. dexamethasone) given to mothers with suspected preterm labour to increase production of surfactant
What is the management of respiratory distress syndrome?
Intubation and ventilation - fully assist breathing if respiratory distress is severe
Endotracheal surfactant - artificial surfactant delivered into lungs via endotracheal tube
Continuous positive airway pressure (CPAP) via nasal mask to keep lungs inflates
Supplementary oxygen - to maintain O2 sats in preterm babies to 91-95%
What are some short term complication of respiratory distress syndrome?
Pneumothorax
Infection
Apnoea
Intraventricular haemorrhage
Pulmonary haemorrhage
Necrotising enterocolitis
What are some long term complications of respiratory distress?
Chronic lung disease of prematurity
Retinopathy of prematurity - more often and severely in neonates with RDS
Neurological, hearing and visual impairment
What is nectrotising enterocolitis (NEC)?
Disorder affecting premature neonates where part of the bowel becomes necrotic - life threatening
Why is NEC life-threatening?
Risk of perforation and peritonitis and shock
What are the risk factors for developing NEC?
- Low birth weight or very premature
- Formula feeds (less common in babies feb by breast milk feeds)
- Respiratory distress and assisted ventilation
- Sepsis
- Patent ductus arteriosus and other congenital heart disease
How does NEC present?
Intolerance to feeds
Vomiting, particularly with green bile
Generally unwell
Distended, tender abdomen
Absent bowel sounds
Blood in stools
What investigations for NEC?
Blood tests - FBC (thrombocytopenia and neutropenia), CRP (inflammation), capillary blood gas (metabolic acidosis), blood culture for sepsis
Abominal x-ray - for diagnosis in supine position and lateral (on side with patient on back) or lateral decubitus (from side with neonate on side)
What do abdo x-rays with NEC show?
Dilated loops of bowel
Bowel wall oedema (thickened bowel wall)
Pneumatosis intestinalis (gas in the bowel wall and a sign of NEC)
Pneumoperitoneum (free gas in peritoneal cavity, indicates perforation)
Gas in the portal veins
What is the management of NEC?
Nil by mouth
IV fluids
Total parenteral nutrition (TPN)
Abx (to stabalise)
NG tube to drain fluid and gas from stomach
NEC is a surgical emergency - immediate referral to neonatal surgical team - remove the dead bowel tissue (may have temporary stoma)
What are the complications of NEC?
- Perforation and peritonitis
- Sepsis
- Death
- Strictures
- Abscess formation
- Recurrence
- Long term stoma
- Short bowel syndrome after surgery
What is neonatal abstinence syndrome (NAS)
Withdrawal symptoms which happen in neonates of mothers which used substances in pregnancy - symptoms and management is different depending on substance used in pregnancy
Which substances can cause NAS?
- Opiates
- Methadone
- Benzodiazepines
- Cocaine
- Amphetamines
- Nicotine or cannabis
- Alcohol
- SSRI antidepressants
How long does withdrawal take to become apparent?
Most opiates, diazepam, SSRIs, alcohol = 3-72 hours after birth
From methadone and other benzos = 24 hours to 21 days
What are the CNS symptoms of NAS?
Irritability
Increased tone
High pitched cry
Not settling
Tremors
Seizures
What are the vasomotor and respiratory symptoms of NAS?
Yawning
Sweating
Unstable temperature and pyrexia
Tachypnoea (fast breathing)
What are the matabolic and gastrointestinal symptoms of NAS?
Poor feeding
Regurgitation or vomiting
Hypoglycaemia
Loose stoold with a sore nappy area
What is the management of NAS?
- If mother known to use substances then have an alert on notes so neonate = extra monitoring
- Babies kept in with monitoring on NAS chart for at least 2 days (48 hours for SSRI dependance)
- Urine sample can be collected
- Neonate supported in a quiet and dim environment with gentle handling and comforting
- Medical treatment
What is the medical treatment for moderate to severe symptoms?
- Oral morphine sulphate for opiate withdrawal
- Oral phenobarbitone for non-opiate withdrawal
What is the treatment for SSRI withdrawal?
No medical treatment usually required
What are the additional management steps in NAS?
Test for hep B and C and HIV
Safeguarding and social service involvement
Safety-net advice for readmission if withdrawl signs / symptoms occur
Follow up from paediatrics, social services, health visitors and the GP
Support for the mother to stop using substances
Check for the suitability for breastfeeding in mothers with substance abuse
When are the effects of drink in alcohol greatest in pregnancy?
First 3 months of pregnancy
What can alcohol in early pregnancy lead to?
Miscarriage
Small for dates
Preterm delivery
What is fetal alcohol syndrome?
Effects and characteristics:
- Microcephaly (small head)
- Thin upper lip
- Smooth flat philtrum (groove between nose and upper lip)
- Short palpebral fissure
- Learning disability
- Behavioural difficulties
- Hearing and vision problems
- Cerebral palsy
What is congenital rubella syndrome caused by?
Maternal infection with the rubella virus during pregnancy (highest risk in first 3 months)
How to prevent congenital rubella syndrome?
Women planning to become pregnant should have the MMR vaccine - if in doubt rubella immunity can be tested for - if no antibodies then vaccinates with 2 doses of the MMR 3 months apart
Should pregnant women recieve the MMR vaccine?
No - this is a live vaccine (non-immune should be given vaccine after birth)
What are the features of congenital rubella syndrome?
- Congenital cataracts
- Congenital heart disease (PDA and pulmonary stenosis)
- Learning disability
- Hearing loss
What is chicken pox caused by?
Varicella zoster virus (VZV)
Why is chicken pox dangerous in pregnancy?
Causes more severe cases in mother such as varicella penumonitis, hepatitis or encephalitis
Fetal varicella syndrome
Severe neonatal varicella infection if mum is infected around delivery
What is the prevention of chickenpox in pregnancy?
IgG levels for VZV can be tested and if not immune the offered the varicella vaccine before or after pregnancy
How to manage exposure to chickenpox in pregnancy?
- If had previous chickenpox then safe
- If not sure then test VZV IgG levels
- If not immune then treated with IV varicella immunoglobulins as prophylaxis against developing chickenpox (given within 10 days of exposure)
How to treat chickenpox rash?
Oral aciclovir if present within 24 hours and more than 20 weeks gestation
What are the typical features of congenital varicella syndrome?
Fetal growth restriction
Microcephaly, hydrocephalus and learning disability
Scars and significatn skin changes following the dermatomes
Limb hypoplasia (underdeveloped limbs)
Cataracts and inflammation in the eye (chorioretinitis)
How often does congenital varicella syndrome occur?
1% of cases of chickenpox in pregnancy - when there is infection in first 28 weeks
What does congenital cytomegalovirus occur?
Maternal CMV infection during preganancy
How is CMV spread?
In the infected saliva or urine of asymptomatic children
Is congenital CMV common?
No - most cases of CMV in preganancy don’t cause congenital CMV
What are the features of congenital CMV?
- Fetal growth restriction
- Microcephaly
- Hearing loss
- Vision loss
- Learning disability
- Seizures
What causes congenital toxoplasmosis?
Infection with the toxoplasma gondii parasite during pregnancy
How is Toxoplasmosis gondii spread?
Contamination with faeces from cat that is a host of the parasite
What is the classic triad of features of toxoplasmosis?
- Intracranial calcification
- Hydrocephalus
- Chorioretinitis
How is congenital zika virus spread?
By host Aedes mosquitos in areas of the world where its prevant
Having sex with someone infected with the virus
What are the symptoms of infection with zika virus, what does it cause in pregnancy?
No symptoms to a mild flu like illness
Congenital Zika syndrome
What are the features of congenital zika syndrome?
Microcephaly
Fetal growth restriction
Other intracranial abnormalities - ventriculomegaly, cerebellar atrophy
What is the management of zika virus in pregnancy?
Testing for: viral PCR, antibodies to the Zika virus
Referral to fetal medicine to monitor pregnancy
No treatment for virus
What is sudden infant death syndrome (SIDS)?
Sudden unexplained death in an infant - aka cot death - usually occuring in first 6 months of life
What are the risk factors for SIDS?
Premature
Low birth weight
Smoking during pregnancy
Male baby (only slightly increased risk)
How to minimise the risk of SIDS?
- Put baby on back when unsupervised
- Keep head uncovered
- Place feet at end of bed to prevent sliding under blanket
- Keep cot clear of toys / blankets
- Comfortable room temp (16-20C)
- Avoid smoking or handling after smoking
- Avoid co-sleeping, particularly on sofa
- If co-sleeping avoid alcohol, drugs, smoking, sleeping tablets or deep sleepers
How to counsel patient on SIDS?
Empathise - don’t imply blame - discuss reducing risk
What is the support for patients affected by SIDS?
Lullaby trust - charity to help support families - bereavement counselling shoud be available
What support do patients who have been affected by SIDS get for next child?
CONI - care of next infant team help with next infant - providing extra support and home visits, resus training and access to equipment such as movement monitors which alarm if baby stops breathing
