PAEDS 2: Neonates and Development Flashcards
What is the criteria for the APGAR score?
Appearance (0 = blue/pale, 1=blue extremities, 2= no cyanosis)
Pulse rate (0 = <60, 1 = 60-100, 2 = >100)
Grimace (0 = no response, 1 = aggressive stimulation needed for cry, 2 = cries on stimulation)
Activity (0 = absent/floppy, 1 = some flexion, 2 = flexes + resists extension)
Respiratory effort (0 = absent, 1 = weak/gasping, 2 = strong cry)
How often is APGAR done and what are the threshold levels?
Done at 1 and 5 minutes post-birth and continued if score under 7.
Totals:
7+ = normal
4-6 = low
3 or less = critically low
(resuscitation should begin before 1 minute score if critically unwell)
Outline neonatal life support for a term baby
- dry/wrap, stimulate, keep warm, delay cord clamping if possible
- assess APGAR
- ensure open airway (if preterm consider CPAP)
- if gasping/not breathing give 5 inflations in air, apply PEEP, SpO2 and ECG if possible
- reassess
- if chest not moving, check positions, 2 person support, consider sunction and laryngeal mask, repeat inflation breaths
- reassess
- if HR not detectable or <60bpm after 30 secs of ventilation do 3:1 chest compression to ventilation, increase O2 to 100% and consider intubation
- reassess and if still no recovery gain vascular access and administer drugs
Outline neonatal life support for a preterm baby <32 weeks
place undried in plastic wrap + radiant heat
inspired oxygen of 21-30% if 28-31 weeks gestation or 30% if <28 weeks gestation
if giving inflations start with 25cm H2O
How do you assess neonatal cyanosis (blue baby)?
Hyperoxia test - give 100% O2 for 10 mins then do ABG and assess PaO2
What does a PaO2 >15kPa on the hyperoxia test suggest?
Respiratory cause of neonatal cyanosis e.g. NRDS, transient tachypnoea, meconium aspiration
What does a PaO2 <15kPa on the hyperoxia test suggest?
Cardiac cause of neonatal cyanosis e.g. tetralogy of fallot, transposition of great arteries, tricuspid atresia, ebstein’s anomaly
What would imaging and treatment be for NRDS?
CXR = ground-glass lung apperance
RF = prematurity
Mx = surfactant therapy
What would imaging and treatment be for transient tachypnoea of the newborn?
CXR = fluid on horizontal fissure
Mx = resolves spontaneously
What would imaging and treatment be for meconium aspiration?
CXR = lung overinflation, patches of collapse and consolidation
RF = macroscomia
Mx = IV Abx
What would investigations show for tetralogy of fallot?
CXR = boot shaped heart
Cyanosis in days, on exertion (tet spells)
ESM
What would investigations show for transposition of great arteries?
CXR = round heart
Cyanosis in hours
Loud S2, no murmur
What would investigations show for tricuspid atresia?
CXR = prominent aortic root
Cyanosis upon minutes
ESM
How are cardiac causes of neonatal cyanosis managed?
Prostaglandin infusion + delayed surgery
What are the steps of NIPE (newborn infant physical examination)?
- General measurements (height, weight, head circumference, abdominal circumference etc.)
- General inspection (tone, look at spine, moles, skin abnormalities, looking at feet and hands etc., primitive reflexes)
- Eyes (red reflex on both eyes, absent red light reflex = sign of congenital cataracts)
- Heart (murmurs, pulses esp. femoral, if absent or asymmetrical may indicate narrowing of aorta)
- Hips (DDH tests)
- External genitalia
What primitive reflexes are tested in the NIPE?
Placing reflex - when dorsum of foot touches surface, steps onto it (lasts 3/12)
Palmar grasp - lasts 3/12
Rooting reflex - turns head if touched near mouth
Sucking reflex - sucks nipple or teat placed in mouth
Asymmetric tonic neck reflex (ATNR) - fencing posture on turning head to one side (lasts 5/12)
Moro reflex - symmetrical abduction and extension followed by flexion and adduction of arms on sudden head extension (lasts 3/12)
What does an absence of the red light reflex in a newborn signify?
Congenital cataracts (may be secondary to TORCH infection, genetic syndromes e.g LHON etc.)
How can neonatal murmurs be classified?
Cyanotic
Non-cyanotic
Innocent
How does a cyanotic murmur present?
Right to left shunt (more life threatening than left to right)
ESM (except for TGA)
What congenital heart defects cause non-cyanotic murmurs?
1) Left to right shunts: PDA, ASD, VSD
2) Outflow obstructions: valve stenosis, coarctation of aorta
How does a PDA present?
Gibson murmur - continuous machine like murmur
How does an ASD present?
ESM + fixed S2 splitting
Primary = foramen ovale
Secondary = defect of atrial septum
How does VSD present?
If large = soft PSM + apical MDM + loud P2
If small = loud PSM + quiet P2
How does valve stenosis present?
ESM + ejection click + quiet A2/P2
How does coarctation of aorta present?
ESM (radiates to scapula/back) + pulse asymmetry/absence
What are features of innocent murmurs?
soft, asymptomatic, systolic, LSE, normal HS
How is a cyanotic heart murmur managed?
Prostaglandin infusion (keep PDA open) + delayed surgery
How is a PDA managed?
Indomethacin - coil closure/ligation at 1yo
How is an ASD managed?
Endovascular occlusive device or surgical repair at 3yo
How is a VSD managed?
if large = CDC = calories, diuretics (captopril); surgery at 3-6mths
if small = self limiting
How is a valve stenosis managed?
Balloon angioplasty
How is a coarctation of aorta managed?
prostaglandin infusion -> surgical repair/balloon angioplasty
What tests are used for assessing whether there’s DDH in a neonate?
Barlow’s test = promoting femoral head dislocation by applying posterior force on knee and adducting baby’s legs
Ortolani’s test = reducing hip into place by applying anterior force on knee and abducting baby’s legs
What is important to assess when checking external genitalia of a newborn?
Hypospadias (urethral opening in wrong place), undescended testes, ambiguous genitalia etc.
What are differentials for a “floppy baby”?
Down’s syndrome = characteristic facies, trisomy 21
Hypothyroidism = abnormal TFTs, dry skin, constipation, iodine deficiency in pregnancy
Hypoglycaemia = jittery, seizures, diabetic mother - SGA or LGA baby, BM <1.4mmol/L
HIE/intracranial bleed = hx prolonged/traumatic delivery, intraventricular haemorrhage on USS
What are the mechanisms behind Down’s syndrome?
Trisomy 21 caused by:
- meiotic non-disjunction (MOST COMMON)
- robertsonian translocation
- mosaicism
What are features of Down’s syndrome by body system?
FACE = epicanthic folds, up-slanting eyelids, flat profile
HEART = endocardial cushion defects (AVSD, ASD)
STOMACH = Hirschsprung’s, duodenal atresia
EARS = low set small ears, recurrent OME
BRAIN = dementia, learning difficulties, epilepsy
HANDS & FEET = clindactyly, single palmar crease, wide sandal gap
What investigations would you do to find potential complications of Down’s syndrome?
Echo - for AVSD/VSD
USS abdomen - for Hirschsprung’s/duodenal atresia
AXR - duodenal atresia shows double bubble sign (stomach + duodenal bubble)
Barium enema - hirschsprung’s has no fluid level (whereas meconium ileus does)
What is Turner’s syndrome?
45XO
What are some features of Turner’s syndrome?
EXTERNALLY = short stature, webbing of neck, broad chest, widely spaced nipples, pigmented naevi, peripheral lymphoedema, cubitus valgus
INTERNALLY = coarctation of aorta, bicuspid aortic valve, streak ovaries, infertility, amenorrhoea
What investigations should be done for neonatal jaundice?
Bedside = transcutaneous BR, urine sample
Bloods = total serum BR, direct Coombs test, direct serum BR, FBC, reticulocyte count, blood smear, LFTs, blood cultures, viral screen
Imaging = abdo USS, percutaneous liver biopsy
What does it mean if there is neonatal jaundice and there is a Coombs +ve test?
Iso-immune reaction i.e. ABO or Rh incompatibility
What are causes of neonatal jaundice w/unconjugated bilirubin?
Physiological
OR
Pathological (haemolytic or non-haemolytic)
What are physiological causes of neonatal jaundice?
Prematurity
Breastfeeding jaundice (insufficient feeding leads to high bilirubin- PC within 1w)
Breastmilk jaundice (breast milk itself is causing high bilirubin, PC >10d)
What are non-haemolytic causes of neonatal jaundice?
Sepsis
Cephalohaematoma
Hypothyroidism
Gilbert’s
Crigler-Najaar
Ix = septic screen, TFTs, PC liver biopsy
What are signs of haemolytic neonatal jaundice?
high LDH, high reticulocytes, abnormal smear, low Hb
What is classed as pathological jaundice in a neonate?
presenting in first 24h or has lasted beyond 1w
What are intrinsic/coombs -ve causes of haemolytic neonatal jaundice?
Enzyme deficiencies
Membrane defect
Haemoglobinopathies
What are extrinsic/coombs +ve causes of haemolytic neonatal jaundice?
ABO or Rh incompatibility
What is important about conjugated bilirubin when investigating neonatal jaundice?
It’s always pathological
What are intrahepatic causes of conjugated bilirubin neonatal jaundice and what investigations would you see?
IX:
Deranged LFTs
Liver dysfunction markers
CAUSES:
Infections
Drugs
Genetic/metabolic syndromes
What are extrahepatic causes of conjugated bilirubin neonatal jaundice and what investigations would you do?
IX: Abdo USS
CAUSES:
Biliary atresia (MOST WORRIED ABOUT THIS ONE - needs surgery)
Choledochal cysts
CF
Galactosaemia
What are some differentiators between congenital causes of neonatal jaundice?
uBR = Gilbert’s syndrome (otherwise normal), Crigler-Najaar (hypotonia, ocular palsy)
cBR = Dubin-Johnson syndrome (black liver on biopsy), Rotor syndrome (normal LFTs, normal colour on biopsy), Hepatocellular insult
How would you manage physiological neonatal jaundice?
Reassurance
Feeding optimisation
Phototherapy
How would you manage an uBR neonatal jaundice?
Phototherapy
Exchange transfusion
(IMPORTANT TO TREAT DUE TO RISK OF KERNICTERUS)
How would you manage a cBR neonatal jaundice?
Treat underlying cause
Kasai procedure (for biliary atresia)
What are the developmental milestone domains?
Gross motor
Vision and fine motor
Hearing, speech and language
Social, emotional and behavioural
What are red flags for gross motor development?
6mths = head control
9mths = sits unsupported
12mths = stands w/support
18mths = walks independently
Hand preference before 1yo
What are red flags for vision and fine motor development?
3mths = fixes and follows
6mths = reaches for objects
9mths = transfers
12mths = pincer grip
What are red flags for hearing, speech and language development?
6mths = babble
9mths = consonant babble
18mths = 6 words
2yo = joins words
2.5 yo = 3-word sentences
What are red flags for social, emotional and behavioural development?
6wks = smiles
9mths = fear of strangers
18mths = feeds self/spoon
2-2.5yo = symbolic play
3-3.5yo = interactive play
What are some causes of a gross motor delay? (how could you categorise differentials?)
Physical causes i.e. muscle/power abnormalities
Developmental causes i.e. maturational delay
What are some physical causes of gross motor delay?
Hypertonic - Cerebral palsy
Hypotonic - Down’s syndrome, Hypothyroidism
Normal tone - Muscle dystrophies, Duchenne’s, Becker’s
What are some developmental causes of gross motor delay?
Later walkers
Neglect
Learning disabilities
What is a classic sign of Duchenne’s muscular dystrophy?
Gower’s sign - using hands to stand from sitting
What investigations and management would you do for gross motor delay?
Bedside = full developmental assessment
Bloods = creatine kinase, autoimmune screen, genetic screen
Imaging = CT head
Specialised tests = muscle biopsy, NCS, EMG
Mx = OP, OT, genetic counselling
What are some physical problems that cause speech delay?
Articulation = cleft lip/palate
Conductive hearing impairment = glue ear
Sensorineural hearing impairment = TORCH infection, meningitis, iatrogenic, SOL
What are some developmental problems that cause speech delay?
Maturational delay = late talkers, neglect, learning disabilities
Social communication = ASD
What investigations would you do for speech delay?
Bedside = full developmental assessment, otoscopy
What hearing tests are done during newborn screening?
AOEA (automated otoacoustic emission assessment)
if this is abnormal then do AABR (automated auditory brainstem response)
What hearing test is done for <3yo?
VRA (visual reinforced audiometry)
What hearing test is done for >3yo?
PTA (pure tone audiometry)
How is hearing impairment managed?
Conductive/glue ear = Grommet (drains fluid)
Sensorineural = hearing aids
What are physiological causes of failure to thrive?
Familial short stature = following growth centile within predicted parental height range, normal bone age
Consitutional delay of growth = delayed bone age
What are pathological causes of failure to thrive and their features?
Genetic syndromes (dysmorphic features, disproportion) = Down’s, Turner’s, Noonan’s, Achondroplasias
Nutrition and general health (falling across centiles, weight < height, delayed bone age) = malabsorption, chronic illness, psychosocial neglect
Endocrine (falling across centiles, weight > height, delayed bone age) = hypothyroidism, GH deficiency, steroid excess
What investigations would you do for failure to thrive presentation where a child is falling across centiles?
Is dependent on age
Bedside = stool sample (faecal calprotectin)
Bloods = FBC, LFTs, U&Es, TFTs, anti-TTG, karyotype/microarray, IGF-1, bone profile, CRP/ESR
Imaging = XR non dominant hand
