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Paediatrics > Paediatrics Neonatology > Flashcards

Paediatrics Neonatology Flashcards

1
Q

What is surface tension?

A

Attraction of the molecules in a liquid to each other

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2
Q

What are alveoli?

A

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)

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3
Q

What is surfactant?

A

Fluid produced by type II alveolar cells containing proteins and fats - reduces surface tension of the fluid in the lungs

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4
Q

What is the result of surfactant?

A

Maximises surface area of the alveoli

Reduces force needed to expand alveoli

Thus surfactant increases lung compliance

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5
Q

When do type II alveolar cells start producing surfactant?

A

Between 24 and 34 weeks gestation

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6
Q

What helps clear fluid from the lungs at birth?

A

Thorax is squeezed as it passes through vagina

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7
Q

What is relseased by the neonate in response to the stress of labour?

A

Adrenalin and cortisol (stimulates respiratory effort)

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8
Q

Why does the foramen ovale close at birth? What does it become?

A

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

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9
Q

Why does the ductus arteriosus close at birth?

A

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

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10
Q

Why does the ductus venosus stop functioning after birth?

A

Umbilical cord is clamped and there is no blood flow in the umbilical veins - this structurally closes and becomes the ligamentum venosum

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11
Q

What is the result of hypoxia during labour and birth?

A

Bradycardia

Reduced consciousness

Drop in respiratory effort

Extended hypoxia = hypoxic-ischaemic encephalopathy (HIE) - potentially cerebral palsy

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12
Q

What are some issues in neonatal resuscitation?

A

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

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13
Q

What are the principles of neonatal resuscitation?

A

Warm baby

Calculate APGAR score

Stimulate breathing

Inflation breaths

Chest compressions

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14
Q

How to warm the baby?

A

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

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15
Q

When and how is the APGAR score calculated?

A

1, 5 and 20 minutes whilst resuscitation continues (used as an indicator of progress)

Lowest score is 0 and highest is 10

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16
Q

How to stimulate the baby to breath?

A

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

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17
Q

When are inflation breaths given?

A

When neonate is gasping or not breathing despite adequate initial stimulation

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18
Q

How are inflation breaths given?

A

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)

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19
Q

What should be used when performing inflation breaths in term/near term babies or pre-term babies?

A

Term = Air

Pre-term = air and oxygen (aim for gradual rise in sats not exceeding 95%)

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20
Q

How to perform chest compressions?

A

Start chest compressions if heart rate below 60bpm despite resus and inflation breaths

Performed at 3:1 ratio with ventilation breaths

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21
Q

What should be given in severe situations during neonatal resus?

A

IV drugs and intubation

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22
Q

What may babies with hypoxic-ischaemic encephalopathy (HIE) benefit from?

A

Therapeutic hypothermia with active cooling (must have gestational age >= 36 weeks and weight greater than 1800g)

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23
Q

Outline A-E assessment in a child?

A

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
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24
Q

Complete the following table:

A
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25
Q

What is placental transfusion?

A

Blood from the umbilical cord entering the circulation of the body

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26
Q

What are the benefits of delayed cord clamping?

A

Improved haemoglobin

Iron stores

Blood pressure

Reduction in intraventricular haemorrhage

Reduction in necrotising enterocolitis

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27
Q

What is an apparent negative effect of delayed cord clamping?

A

Neonatal jaundice (requiring more phototherapy)

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28
Q

How long should the delay in cord clamping be?

A

1 minute (clamped sppner in those that need resus)

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29
Q

What is the care for neonates immediately after birth?

A

Skin to skin

Clamp umbilical cord

Dry baby

Keep warm in hat and blankets

Vit K

Label baby

Measure weight and length

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30
Q

Why and how are babies given vitamin K?

A

Babies are deficient

IM injection in the thigh

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31
Q

Why is vitamin K given after birth?

A

Prevents bleeding: intracranial, from umbilical stump and GI bleeding

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32
Q

How else may vitamin K be given?

A

Orally - longer to act and requires doses at birth, 7 days and 6 weeks

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33
Q

Why is skin to skin contact important?

A

Helps warm baby

Improves mother and baby interaction

Calms baby

Improves breast feeding

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34
Q

What forms part of management once mum and baby are out of delivery room?

A

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

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35
Q

When is the blood spot screening test performed on newborns?

A

Day 5 or 8 at latest after consent from parent

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36
Q

What does the blood spoot screening test look for?

A

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

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37
Q

How long do results from the blood spot screening test take to come back?

A

6-8 weeks

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38
Q

When is a newborn examination performed?

A

72 hours after birth and repeated at 6-8 weeks

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39
Q

What are the principles of the newborn examination?

A

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
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40
Q

How to measure oxygen saturations in newborn examination?

A

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)

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41
Q

Where is the ductus arteriosus and what is its function?

A

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

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42
Q

Why is the ductus arteriosus important?

A

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

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43
Q

Where are pre-ductal saturations measured?

A

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

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44
Q

Where are post-ductal saturations measured?

A

Either foot (these recieve blood from the descending aorta - occuring after the ductus arteriosus)

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45
Q

What to look for in the general appearance of a neonate?

A

Colour (pink is good)

Tone

Cry

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46
Q

What should be looked for on the head examination of a newborn?

A

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

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47
Q

What to examine on a newborns shoulders and arms?

A

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

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48
Q

What to examine on chest of a newborn baby?

A

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

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49
Q

What to look for in the abdomen on a newborn examination?

A

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

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50
Q

What to look for in the genitals in a newborn examination?

A

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

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51
Q

What to look for in the legs for a newborn examination?

A

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

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52
Q

What to look for in the back for a newborn examination?

A

Inspect and palpate the spine for curvature, spina bifida and pilonidal sinus

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53
Q

What to look for on reflexes for newborn examination?

A

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

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54
Q

What to look for on skin on newborn examination?

A

Haemangiomas

Port wine stains

Mongolian blue spot

Cradle cap

Desquamation

Erythema toxicum

Milia

Acne

Naevus simplex (“stork bite”)

Moles

Transient pustular melanosis

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55
Q

What are talipes?

A

Clubfoot = ankle is in a supinated position rolled inwards (can be positional or structural)

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56
Q

What is the difference between positional and structural talipes?

A

Positional = muscles are tights, bones unaffected - foot can move into normal position (requires physio)

Structural = involves bones and requires referral to orthopaedic surgeon

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57
Q

Do skin findings on newborn examination require action?

A

No - many will fade with time

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58
Q

Do haemangiomas on newborns require treatment?

A

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)

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59
Q

What are port wine stains?

A

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

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60
Q

What can port wine stains be related to?

A

Sturge-Weber syndrome with visual impairment, learning difficulties, headaches, epilepsy and glaucoma

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61
Q

What is the management of clunky / clicky hips?

A

Referral for a hip ultrasound to rule out developmental dysplasia of the hips

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62
Q

What do cephalohaematomas require monitoring for?

A

Jaundice and anaemia

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63
Q

What do bony injuries in newborn examination require?

A

X-ray to look for fractures (e.g. clavicular fracture)

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64
Q

How to manage soft systolic murmurs in newborns?

A

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)

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65
Q

How to manage suspicion of heart failure / congenital heart disease?

A

Referral to cardiology for an ECG and echocardiogram

If unwell then admit to neonatal unit and immediate management

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66
Q

How to complete a newborn examination?

A

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

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67
Q

What is caput succedaneum?

A

Oedema collecting in the scalp outside of the periosteum caused by pressure to a specific area of the scalp during prolonged or instrumental delivery

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68
Q

What is the periosteum?

A

Layer of dense connective tissue outside the skin (doesnt cross the sutures)

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69
Q

Does caput succedaneum require any treatment?

A

No treatment and resolves in a few days

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70
Q

What is a cephalohaematoma?

A

Collection of blood between the periosteum and the skull

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71
Q

When does a cephalohaematoma occur?

A

Traumatic, prolonged or instrumental delivery (described as traumatic subperiosteal haematoma)

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72
Q

Why does the blood not cross the suture line in cephalohaematoma?

A

Blood is below the periosteum

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73
Q

What is the management of cephalohaematoma?

A

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)

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74
Q

When can facial paralysis occur in childbirth?

A

During forceps delivery - function normally returns spontaneously in a few months - if not then neurosurgical input required

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75
Q

When can Erb’s palsy occur in childbirth?

A

Injury to the C5/C6 nerves in the brachial plexus

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76
Q

What is Erb’s palsy associated with?

A

Shoulder dystocia

Traumatic / instrumental delivery

Large birth weight

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77
Q

What does damaged C5/C6 nerves present as?

A

Weakness of:

Shoulder abduction

External rotation

Arm flexion

Finger extension

Leaving arm having a “waiters tip”

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78
Q

What is the treatment of Erb’s palsy after birth?

A

Function normally returns spontaneously within a few month (if not then require neurosurgical input)

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79
Q

What is a fractured clavicle during childbirth associated with?

A

Shoulder dystocia

Traumatic delivery

Instrumental delivery

Large birth weight

80
Q

How can a fractured clavicle be picked up on during newborn examination?

A

Noticable lack of movement / asymmetry

Asymmetry of the shoulders with affected shoulder lower than normal

Pain on movement of the arm

81
Q

How can a fractured clavicle be confirmed?

A

Ultrasound / X-ray

82
Q

What is the management of a fractured clavicle?

A

Conservative with immobilisation of the affected arm

83
Q

What is the main complication of a fractured clavicle?

A

Injury to the brachial plexus with a subsequent nerve palsy

84
Q

What organisms commonly cause neonatal sepsis?

A

Group B streptococcus (GBS)

Escherichia coli (e. coli)

Listeria

Klebsiella

Staphylococcus aureus

85
Q

What are the risk factors of neonatal sepsis?

A

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)

86
Q

What are the clinical features of neonatal sepsis?

A

Fever

Reduced tone and activity

Poor feeding

Respiratory distress or apnoea

Vomiting

Tachycardia or bradycardia

Hypoxia

Jaundice within 24 hours

Seizures

Hypoglycaemia

87
Q

What are the red flags of neonatal sepsis?

A

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

88
Q

What is the management of neonatal sepsis?

A

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)

89
Q

What are the antibiotic choice in neonatal sepsis?

A

Benzylpenicillin and gentamycin as first line

3rd gen cephalosporin (e.g. cefotaxime) may be given as alternative in lower risk babies

90
Q

What is the ongoing management of neonatal sepsis?

A

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

91
Q

When to consider a lumbar puncture in neonatal sepsis?

A

Any of CRP results are more than 10

92
Q

When does hypoxic ischaemic encephalopathy occur?

A

In neonates as a result of hypoxia during birth

93
Q

What can result from HIE?

A

Cerebral palsy

94
Q

When to suspect HIE?

A

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

95
Q

What are some causes of HIE?

A

Maternal shock

Intrapartum haemorrhage

Prolapsed cord

Nuchal cord (cord is wrapped around the neck of the baby)

96
Q

What is the Sarnat staging system for HIE?

A
97
Q

What is the management of HIE?

A

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

98
Q

How does therapeutic hypothermia work?

A

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

99
Q

How is conjugated bilirubin excreted?

A

Via the biliary system into GI tract and via the urine

100
Q

Why does physiological jaundice happen?

A

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

101
Q

What are the causes of neonatal jaundice (increased production of bilirubin or decreased clearance of bilirubin)

A

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
102
Q

What is jaundice in the first 24 hours of life?

A

Pathological - urgent investiation - neonatal sepsis is a common cause

103
Q

Why is jaundice in premature neonates more concerning?

A

Due to immature liver there may be more bilirubin increasing risk of kernicterus which is brain damage due to high bilirubin levels

104
Q

Why are babies that are breast fed more likely to have neonatal jaundice?

A
  • 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
105
Q

What is haemolytic disease of the newborn?

A

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

106
Q

How does haemolytic disease of the newborn occur?

A

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

107
Q

What is prolonged jaundice?

A

More than 14 days in full term babies

More than 21 days in premature babies

108
Q

What can cause prolonged jaundice?

A

Biliary atresia

Hypothyroidism

G6PD deficiency

109
Q

What are the investigations for neonatal jaundice?

A

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

110
Q

What is the management of jaundiced neonates?

A

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

111
Q

What are the treatment options for neonatal jaundice?

A

Phototherapy

Exchange transfusion (for extremely high levels) - removing blood from neonate and replacing with donor blood

112
Q

How is phototherapy used to treat neonatal jaundice?

A

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

113
Q

How does Kernicterus (a type of brain damage) occur?

A

Excessive bilirubin levels can cause damage to the CNS (as it can cross the blood-brain barrier)

114
Q

What can kernicterus cause?

A

Cerebral palsy

Learning disability

Deafness

115
Q

What is prematurity?

A

Birth before 37 weeks

116
Q

When should resuscutation be carefully considered?

A

Under 500 grams and before 24 weeks

117
Q

What are prematurity levels?

A

Extreme preterm = under 28 weeks

Very preterm = 28-32 weeks

Moderate to late preterm = 32-37 weeks

118
Q

What are some association with prematurity?

A

Social deprivation

Smoking

Alcohol

Drugs

Overweight or underweight mother

Maternal co-morbidities

Twins

Personal or family history of prematurity

119
Q

When should delaying birth be considered?

A

Women with a history of preterm birth

Ultrasound demonstrating a cervical length of 25mm or less before 24 weeks gestation

120
Q

How can birth be delayed?

A

Prophylactic vaginal progesterone (progesterone suppository in the vagina)

Prophylactic cervical cerclage (putting a suture in the cervix to hold it closed)

121
Q

What methods to improve the outcome in preterm labour?

A

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

122
Q

What issues in early life does prematurity cause?

A

Respiratory distress syndrome

Hypothermia

Hypoglycaemia

Poor feeding

Apnoea and bradycardia

Neonatal jaundice

Intraventricular haemorrhage

Retinopathy of prematurity

Necrotising enterocolitis

Immature immune system and infection

123
Q

What are the long term effects of prematurity?

A

Chronic lung disease of prematurity (CLDP)

Learning and behavioural difficulties

Susceptibility to infections, particularly respiratory tract infections

Hearing and visual impairment

Cerebral palsy

124
Q

What are apnoeas?

A

Defined as periods when breathing stops spontaneously for more than 20 seconds or shorter periods with oxygen desaturation or bradycardia

125
Q

When are apnoeas most common?

A

Premature neonates - all babies less than 28 weeks gestation

126
Q

What is the cause of apnoeas?

A

Immaturity of the autonomic nervous system which controls respiration and heart rate

127
Q

What are the causes of apnoeas?

A

Infection

Anaemia

Airway obstruction (may be positional)

CNS pathology, such as seizures or haemorrhage

Gastro-oesophageal reflux

Neonatal abstinence syndrome

128
Q

What is the management of apnoeas?

A
  • 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
129
Q

Who does retinopathy of prematurity affect?

A

Preterm (before 32 weeks)

Low birth weight

130
Q

What can abnormal development of blood vessels in the retina cause?

A

Scarring

Retinal detachment

Blindness (treatment can prevent this - screening is important)

131
Q

When is retinal blood vessel development?

A

From 16 to 37/40 weeks (grow from middle of retina outwards)

132
Q

What is retinal vessel formation stimulated by?

A

Hypoxia - normal condition in the retina (in preterm babies this stimulant is removed)

133
Q

What happens when hypoxia returns in retina of preterm?

A

Response of excessive blood vessels (neovascularisation) as well as scar tissue - can cause retinal detachment

134
Q

What are the three zones of the retina?

A

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

135
Q

How are the retinal areas described?

A

Clock face = disease from 3 o’clock to 5 o’clock

136
Q

How are the areas of disease in retinopathy of prematurity described?

A

Stage 1 (slightly abnormal vessel growth) to stage 5 (complete retinal detachment)

137
Q

What is “plus disease” on retinopathy of prematurity?

A

Additional findings such as tortuous vessels and hazy vitreous humour

138
Q

Which babies should be screened for ROP?

A

Born before 32 weeks or under 1.5kg

139
Q

When should screening for ROP be performed?

A

30 – 31 weeks gestational age in babies born before 27 weeks

4 – 5 weeks of age in babies born after 27 weeks

140
Q

How often should screening for ROP occur?

A

Every 2 weeks and cease when retinal vessels enter zone 3 (usually around 36 weeks gestation)

141
Q

What is the treatment of ROP?

A

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
142
Q

Who does respiratory distress syndrome affect?

A

Premature neonates - born before the lungs start producing adequate surfactant (usually below 32 weeks)

143
Q

What does an X-ray show for respiratory distress syndrome?

A

Ground glass appearance

144
Q

What is the pathophysiology in respiratory distress syndrome?

A

Inadequate surfactant causing high surface tension in alveoli resulting in hypoxia, hypercapnia (high CO2) and respiratory distress

145
Q

What is the prevention of respiratory distress syndrome?

A

Antenatal steriods (i.e. dexamethasone) given to mothers with suspected preterm labour to increase production of surfactant

146
Q

What is the management of respiratory distress syndrome?

A

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%

147
Q

What are some short term complication of respiratory distress syndrome?

A

Pneumothorax

Infection

Apnoea

Intraventricular haemorrhage

Pulmonary haemorrhage

Necrotising enterocolitis

148
Q

What are some long term complications of respiratory distress?

A

Chronic lung disease of prematurity

Retinopathy of prematurity - more often and severely in neonates with RDS

Neurological, hearing and visual impairment

149
Q

What is nectrotising enterocolitis (NEC)?

A

Disorder affecting premature neonates where part of the bowel becomes necrotic - life threatening

150
Q

Why is NEC life-threatening?

A

Risk of perforation and peritonitis and shock

151
Q

What are the risk factors for developing NEC?

A
  • 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
152
Q

How does NEC present?

A

Intolerance to feeds

Vomiting, particularly with green bile

Generally unwell

Distended, tender abdomen

Absent bowel sounds

Blood in stools

153
Q

What investigations for NEC?

A

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)

154
Q

What do abdo x-rays with NEC show?

A

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

155
Q

What is the management of NEC?

A

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)

156
Q

What are the complications of NEC?

A
  • Perforation and peritonitis
  • Sepsis
  • Death
  • Strictures
  • Abscess formation
  • Recurrence
  • Long term stoma

- Short bowel syndrome after surgery

157
Q

What is neonatal abstinence syndrome (NAS)

A

Withdrawal symptoms which happen in neonates of mothers which used substances in pregnancy - symptoms and management is different depending on substance used in pregnancy

158
Q

Which substances can cause NAS?

A
  • Opiates
  • Methadone
  • Benzodiazepines
  • Cocaine
  • Amphetamines
  • Nicotine or cannabis
  • Alcohol
  • SSRI antidepressants
159
Q

How long does withdrawal take to become apparent?

A

Most opiates, diazepam, SSRIs, alcohol = 3-72 hours after birth

From methadone and other benzos = 24 hours to 21 days

160
Q

What are the CNS symptoms of NAS?

A

Irritability

Increased tone

High pitched cry

Not settling

Tremors

Seizures

161
Q

What are the vasomotor and respiratory symptoms of NAS?

A

Yawning

Sweating

Unstable temperature and pyrexia

Tachypnoea (fast breathing)

162
Q

What are the matabolic and gastrointestinal symptoms of NAS?

A

Poor feeding

Regurgitation or vomiting

Hypoglycaemia

Loose stoold with a sore nappy area

163
Q

What is the management of NAS?

A
  • 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
164
Q

What is the medical treatment for moderate to severe symptoms?

A
  • Oral morphine sulphate for opiate withdrawal
  • Oral phenobarbitone for non-opiate withdrawal
165
Q

What is the treatment for SSRI withdrawal?

A

No medical treatment usually required

166
Q

What are the additional management steps in NAS?

A

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

167
Q

When are the effects of drink in alcohol greatest in pregnancy?

A

First 3 months of pregnancy

168
Q

What can alcohol in early pregnancy lead to?

A

Miscarriage

Small for dates

Preterm delivery

169
Q

What is fetal alcohol syndrome?

A

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
170
Q

What is congenital rubella syndrome caused by?

A

Maternal infection with the rubella virus during pregnancy (highest risk in first 3 months)

171
Q

How to prevent congenital rubella syndrome?

A

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

172
Q

Should pregnant women recieve the MMR vaccine?

A

No - this is a live vaccine (non-immune should be given vaccine after birth)

173
Q

What are the features of congenital rubella syndrome?

A
  • Congenital cataracts
  • Congenital heart disease (PDA and pulmonary stenosis)
  • Learning disability
  • Hearing loss
174
Q

What is chicken pox caused by?

A

Varicella zoster virus (VZV)

175
Q

Why is chicken pox dangerous in pregnancy?

A

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

176
Q

What is the prevention of chickenpox in pregnancy?

A

IgG levels for VZV can be tested and if not immune the offered the varicella vaccine before or after pregnancy

177
Q

How to manage exposure to chickenpox in pregnancy?

A
  • 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)
178
Q

How to treat chickenpox rash?

A

Oral aciclovir if present within 24 hours and more than 20 weeks gestation

179
Q

What are the typical features of congenital varicella syndrome?

A

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)

180
Q

How often does congenital varicella syndrome occur?

A

1% of cases of chickenpox in pregnancy - when there is infection in first 28 weeks

181
Q

What does congenital cytomegalovirus occur?

A

Maternal CMV infection during preganancy

182
Q

How is CMV spread?

A

In the infected saliva or urine of asymptomatic children

183
Q

Is congenital CMV common?

A

No - most cases of CMV in preganancy don’t cause congenital CMV

184
Q

What are the features of congenital CMV?

A
  • Fetal growth restriction
  • Microcephaly
  • Hearing loss
  • Vision loss
  • Learning disability
  • Seizures
185
Q

What causes congenital toxoplasmosis?

A

Infection with the toxoplasma gondii parasite during pregnancy

186
Q

How is Toxoplasmosis gondii spread?

A

Contamination with faeces from cat that is a host of the parasite

187
Q

What is the classic triad of features of toxoplasmosis?

A
  • Intracranial calcification
  • Hydrocephalus
  • Chorioretinitis
188
Q

How is congenital zika virus spread?

A

By host Aedes mosquitos in areas of the world where its prevant

Having sex with someone infected with the virus

189
Q

What are the symptoms of infection with zika virus, what does it cause in pregnancy?

A

No symptoms to a mild flu like illness

Congenital Zika syndrome

190
Q

What are the features of congenital zika syndrome?

A

Microcephaly

Fetal growth restriction

Other intracranial abnormalities - ventriculomegaly, cerebellar atrophy

191
Q

What is the management of zika virus in pregnancy?

A

Testing for: viral PCR, antibodies to the Zika virus

Referral to fetal medicine to monitor pregnancy

No treatment for virus

192
Q

What is sudden infant death syndrome (SIDS)?

A

Sudden unexplained death in an infant - aka cot death - usually occuring in first 6 months of life

193
Q

What are the risk factors for SIDS?

A

Premature

Low birth weight

Smoking during pregnancy

Male baby (only slightly increased risk)

194
Q

How to minimise the risk of SIDS?

A
  • 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
195
Q

How to counsel patient on SIDS?

A

Empathise - don’t imply blame - discuss reducing risk

196
Q

What is the support for patients affected by SIDS?

A

Lullaby trust - charity to help support families - bereavement counselling shoud be available

197
Q

What support do patients who have been affected by SIDS get for next child?

A

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

Paediatrics (18 decks)

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