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Specialties Active > Paeds emergencies, genetics and neonatology > Flashcards

Paeds emergencies, genetics and neonatology Flashcards

1
Q

Recall 2 causes of neonatal collapse

A

Sepsis, CHD

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2
Q

Recall 4 possible causes of jaundice in the neonate

A

Breast milk, sepsis, feeding difficulty, physiological

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3
Q

Recall 4 common causes of rash in the neonate

A

Nappy rash, milia, erythema toxicum, mongolian blue spot

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4
Q

Recall 2 causes of seizures in the neonate?

A

Hypoglycaemia, HIE

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5
Q

Recall 4 milestones that should be reached by one year

A

Standing unsupported, pincer grip, “mama, dada, no”, fear strangers

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6
Q

Recall 5 milestones that should be reached by 18 months

A

Stack 2 blocks, walk unaided, separation anxiety, know 6-12 words, scribbles

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7
Q

Recall 2 milestones that should be reached by 2 years

A

Link 2 words in sentences, understand 2 step commands

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8
Q

Recall the milestones that should be reached by 3 years

A

Gross motor: Hop on one foot, walk upstairs one foot per step, downstairs two feet per step

Fine motor: Draws a circle, bricks in a bridge, makes single cuts in paper with scissors, string of beads

Speech/ language: understands negatives and adjectives

Social: begins to share toys, plays alone without parents, eats with fork and spoon, bowel control

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9
Q

What are the 4 domains of development?

A

Gross motor skills (develop head to toe), fine motor skills, language and speech, social skills

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10
Q

In what period of life should primitive reflexes be present?

A

From birth, to no later than 6 months

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11
Q

Recall the 5 primitive reflexes

A

Moro (sudden head drop –> arms outstretched)
Stepping
Rooting
Palmar and plantar grasp
Atonic neck (fencing posture)

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12
Q

Why do gross motor skills develop from head to toe?

A

That is how myelination develops

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13
Q

At what age should a child run and jump?

A

2.5 years

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14
Q

What is the limit age for walking independently?

A

18 months

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15
Q

At what age should children babble polysyllabically?

A

5 months

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16
Q

At what age should children say 6 words with meaning?

A

18 months

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17
Q

At what age should children be able to smile?

A

6 weeks

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18
Q

How can abnormal progression be classified?

A

Slow but steady, plateau, regression, acute insult

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19
Q

What is tested in the full physical exam (first 72 hours)?

A

Heart, hips, eyes, testes

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20
Q

When is the Guthrie heel prick test done?

A

At 7 days old

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21
Q

When is the new baby review done and what does it involve?

A

2 weeks: safe sleeping, vaccination, feeding, caring, development

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22
Q

How is hearing tested in the neonate, and when is this done?

A

Automated Otoacoustic Emission/ AOAE - at 4 weeks

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23
Q

When is the second full physical exam, and what does it involve?

A

At 6 weeks (done by GP) - DDH testing, testicles, heart, weight, length, vaccination discussion

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24
Q

Recall the timings of the immunisations done within the 1st year of life and what is included in each one

A

1st immunisations:

8 weeks - Men B, rotavirus, 6-in 1 DTaP/IPV/Hib/HepB

2nd immunisations: 12 weeks - also ‘6-in-1’ and rotavirus + pneumococcal

3rd immunisations: 16 weeks - ALSO 6-in-1 and a repeat MenB

4th immunisations: 1 year - 1st MMR + boosters

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25
Q

When is HBV given, and to which infants?

A

At birth, to those whose mother is infected

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26
Q

When is BCG given to eligible infants?

A

At birth

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27
Q

What is included in a health review?

A

Development, behaviour, healthy eating

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28
Q

When are the health reviews conducted?

A

1 and 2 years

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29
Q

When are the 5th immunisations and what do they include?

A

3 years 4 months
DTP, polio, 2nd MMR

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30
Q

What is checked at 4 years?

A

Vision

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31
Q

What is checked on school entry?

A

Height, weight, hearing

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32
Q

When are the 6th and 7th immunisations and what do they include?

A

6th immunisations are at 12-14 years: 2 x HPV (6,11,16,18)

7th immunisations = at 14 years, DTP, MenACWY

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33
Q

Which paediatric milestones are checked at the 1 year health review?

A

Gross motor - they should be walking unsteadily and standing independently

Fine motor - pincer grip (check for no hand dominance)

Hearing/ speech/ language - 2/3 words other than dada/mama with intent

Social/emotional/ behavioural - drink from cup with 2 hands

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34
Q

What is the mnemonic for remembering the components of the 6-in-1 vaccine?

A

Parents Will Immunise Toddlers Because Death -
Polio
Whooping cough
Influenzae B
Tetanus,
B (hepatitis)
Diptheria

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35
Q

What colours of skin would be a red flag in the traffic light system?

A

Pale/ mottled/ ashen/ blue

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36
Q

At what age is a child with fever always considered a red flag in the traffic light system?

A

<3 months

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37
Q

Recall how CPR differs in adults compared to children and neonates

A

Adults: 30:2
Children: 15:2
Neonates: 3:1

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38
Q

In the ABCDE formulation, what comes under ‘disability’?

A

AVPUG - Alert, voice, pain, unresponsive, glucose

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39
Q

What is the most common surgical emergency in newborn babies?

A

Necrotising enterocolitis

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40
Q

Describe the decorticate and decerebrate positions

A

Decorticate = bending wrists up to neck, decerebrate = wrists pointing out, arms straight down by sides

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41
Q

What is SIRS?

A

Generalised inflammatory response, defined by >/= 2 criteria:
Must inculde one of:
- Abnormal temp (<36, >38.5)
- Abnormal WCC
The other criteria are:
- Abnormal HR
- Raised RR

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42
Q

How is a high risk sepsis diagnosed?

A

CVS: hypotension, prolonged cap refil, O2 needed to maintain SpO2
Blood lactate >2
Pale, mottled or non-blanching purpuric rash
RR abnormal or grunting

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43
Q

What is the sepsis 6 pathway in adults?

A

Oxygen
Blood and blood cultures
IV Abx
IV fluids
Check serial lactates
Check urine output

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44
Q

What is the difference between Sepsis and SIRS?

A

Sepsis = SIRS with infection

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45
Q

How is severe sepsis defined?

A

Sepsis with CV dysfunction, ARDS or dysfunction 2 or more organs

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46
Q

How is septic shock defined?

A

Sepsis with CV dysfunction persisting after at least 40mL/kg of fluid resuscitation in one hour

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47
Q

What are the common organisms implicated in early onset neonatal sepsis?

A

GBS, E coli, L monocytogenes

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48
Q

Which organism is most likely to cause late onset neonatal sepsis?

A

Coagulase-negative staphylococcus (CoNS) eg. Staph. Epidermis

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49
Q

Which children with sepsis should have an LP?

A

<1 month old, 1-3 months who appear unwell/ have an WCC <5 or >15

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50
Q

What is the sepsis 6 pathway in children?

A

Give:
1. High-flow oxygen
2. Antibiotics
- Early-onset neonatal = cefotaxime, amikacin + ampicillin
- Late-onset neonatal =meropenem+ amikacin + ampicillin
- >3m old = ceftriaxone)
3. Early senior input
4. Early inotropic support
5. Fluid resus if indicated (20mls/kg 0.9% NaCl over 5-10 mins)

Take:
1. Bloods:
FBC (abnormal WCC?)
U&E + CRP (?urosepsis)
Glucose
Clotting (?DIC)
ABG and lactate

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51
Q

Which Abx are most useful in meningococcal sepsis?

A

IM benzylpenicillin (in the community) or IV cefotaxime (in hospital)

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52
Q

Which Abx are most useful in early onset neonatal sepsis?

A

Most likely to be GBS, L. monocytogenes or E coli so: IV cefotaxime + amikacin + ampicillin

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53
Q

Which Abx are most useful in late onset neonatal sepsis?

A

Most likely to be CoNS (s. epidermis) so: IV meropenem + amikacin + ampicillin

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54
Q

What is opisthotonos?

A

Hyperextension of neck and back

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55
Q

What are the two ‘signs’ indicative of meningitis?

A

Kernig’s sign: pain on leg straightening
Brudzinski’s sign: supine neck flexion –> knee/ hip flexion

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56
Q

What type of rash is often present in meningitis and what type of meningitis is this most common in?

A

Non-blanching - usually meningococcal

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57
Q

How does the HR change throught the course of illness in meningitis?

A

Starts high to compensate for brain ischaemia, then drops to as baroreceptors sense high BP

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58
Q

What symptoms make up Cushing’s triad of high ICP?

A

High BP + low HR + irregular RR

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59
Q

In what order should meningitis investigations be done?

A

First: LP if not contraindicated to identify source of infection
Next:
1. VBG: including glucose and lactate
2. Blood cultures (must be done BEFORE empirical abx started)
3. FBC, CRP, UandE and creatinine
(After this - give broad spec abx at highest possible dose without delay)

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60
Q

As well as sepsis 6 pathway + Abx, what should the management be in meningitis in children?

A
  • Steroids (dexamethosone) if CSF shows purulent CSF, WBC >10000, WCC + protein >1g/L, bacterial gram stain and ONLY if it’s not meningococcal
  • Mannitol (to reduce ICP)
  • IV saline NaCl
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61
Q

What potential longterm complications of meningitis might need to be discussed with a child’s family?

A

Hearing loss, renal failure, neurodevelopmental conditions
Purpura fulminans - the haemorrhagic skin necrosis from DIC

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62
Q

What are the most common causes of viral meningitis?

A

Coxsackie Group B, echovirus

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63
Q

What is encephalitis?

A

Inflammation of the brain parenchyma

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64
Q

What are the 3 possible aetiologies of encephalitis?

A
  1. Direct invasion of cerebellum (eg HSV)
  2. Post-infectious encephalopathy = delayed brain swelling following neuroimmunological response to antigen
  3. Slow virus infection (eg HIV or SSPE following measles)
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65
Q

What are the signs and symptoms of encephalitis?

A

Same as meningitis - might not be able to tell the difference clinically! If there is a behavioural change is more likely to be encephalitis

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66
Q

What are some contraindications for LP?

A

Cardiorespiratory instability
Signs of raised ICP
Thrombocytopaenia
Focal neurology
Coagulopathy
Meningococcal meningitis

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67
Q

How should encephalitis be managed?

A

IV acyclovir (high dose) for 3 weeks - HSV is a rare cause but complications are major so treat empirically

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68
Q

What should be added to the treatment regime if it’s a CMV encephalitis?

A

Ganciclovir and Foscarnet

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69
Q

What is anaphylaxis?

A

Type 1 hypersensitivity reaction - IgG cross-linking with IgE membrane-bound Ab of mast cell/ basophil

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70
Q

What is the most common cause of anaphylaxis in children?

A

Food allergy (85%)

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71
Q

What is the dose of IM adrenaline in paediatric anaphylaxis?

A

1:1,000

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72
Q

When can a repeat dose of IM adrenaline be given in paediatric anaphylaxis treatment?

A

If response after 5 mins is insufficient

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73
Q

After giving adrenaline, how should anaphylaxis be managed?

A

Establish airway + high flow O2
IV fluids (crystalloids)
IV chlorpheniramine
IV hydrocortisone
Salbutamol if wheeze

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74
Q

What is the first thing that must be done on observation of a dry baby at delivery?

A

Note time!

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75
Q

What must be done within the first 30 seconds of a neonatal resuscitation?

A

Assess tone, RR, HR (femoral and brachial) and colour

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76
Q

What must be done within the first 60 seconds of a neonatal resuscitation?

A

If not breathing, open airway and do 5 INFLATION BREATHS
Reassess and repeat until chest movement seen

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77
Q

Once chest movement is seen in a neonatal resuscitation, what should be done next?

A

Ventilate for 30s
Then chest compression and ventillation with a rate of 3:1

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78
Q

If HR remains undetectable/ slow in a neonatal resuscitation, what should be considered?

A

Consider venous access and drugs

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79
Q

When should the Apgar score be used?

A

At 1 min and 5 mins after delivery, and every 5 mins after if condition remains poor

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80
Q

What apgar score is considered normal?

A

> 7

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81
Q

What are the components of the apgar score?

A

Appearance (colour)
Pulse
Grimace
Activity (muscle tone)
Respiratory

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82
Q

What should be considered if, after tracheal intubation, HR does not increase and good chest movement is not achieved in a neonatal resuscitation?

A

DOPE:
Displaced tube
Obstructed tube
Patient (tracheal obstruction? Lung disorder? Shock? Choanal atresia?)
Equipment failure

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83
Q

When should 5 rescue breaths be given in paediatric BLS?

A

DR AB RESCUE BREATHS CDE

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84
Q

At what BPM should chest compressions be done in paediatric BLS?

A

100-120

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85
Q

Recall the signs and symptoms of Patau’s

A

Use mnemonic ‘microcephaly’:
M - mental retardation
13 (trisomy)
C - cleft lip and palate
R - renal
O - omphalocele
C - cardiac
E - eyes small
P - polydactyly
H - holoprosencephaly
L - lbw

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86
Q

Recall some key features of Edward’s syndrome

A

Ears low set
Disability of intellect
Weight low
Omphalocele
Overlapping fingers
Rockerbottom. feet
Renal
D heart
Small mouth and chin

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87
Q

Recall some key features of Down’s

A

Single palmar crease, ‘sandal gap’ abnormality, upslanting palpabral fissures

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88
Q

What is mutated in Noonan’s syndrome?

A

RAS/ MAPK

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89
Q

Recall the features of Noonan’s

A

Webbed neck, trident hairline, pectus excavatum, short stature, pulmonary stenosis

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90
Q

What is the genetic difference between PWS and Angelman’s?

A

PWS = lack paternal 15q, Angelman = lack maternal 15q

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91
Q

What is the genetic mutation in Turner’s?

A

Female missing/ partly missing an X chromosome

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92
Q

Recall some features of Turners

A

Neonatally: pyloric stenosis + cardiac problems
Infertility due to ovarian dysgenesis
Koilonychia
Wide carrying angle
Webbed neck
Bicuspid aortic valve –> aortic coarctation –> ESM over aortic valve

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93
Q

Recall 4 features of Kleinfelter’s

A

Infertility, hypogonadism, gynaecomastia + tall stature

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94
Q

What mutation causes fragile X?

A

CGG trinucleotide expansion - FMR1 gene

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95
Q

Recall the symptoms of Fragile X

A

MALE MOPS
M - macrocephaly
A - autism
L - laxity of joints
E - ears are large and low-set
M - macro-
O - orchidism
P - prolapsed MV complication
S - scoliosis

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96
Q

What is the triad of abnormalities seen when there is maternal rubella during pregnancy

A

Cataracts, deafness, cardiac abnormalities

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97
Q

What is the prognosis for Patau’s syndrome?

A

80% die in first month

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98
Q

What is the prognosis for Noonan’s?

A

Varies massively as penetrance varies massively too

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99
Q

What is the phenotype of Angelman’s?

A

Facial appearance abnormal
Ataxia
Cognitive impairment
Epilepsy

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100
Q

What is the most common heart defect in Down’s syndrome?

A

AVSD

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101
Q

Recall some of the possible later complications of Down’s syndrome

A

Secretory otitis media (75%)
OSA (50-75%)
Learning difficulty
VI Joint laxity

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102
Q

Recall some conditions that those with Down’s are at an increased risk of developing

A

AML, hypothhyroidism, coeliac, epilepsy, early-onset alzheimer’s

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103
Q

What should be checked for annually in those with Down’s syndrome

A

Hearing test, thyroid, eye test, Hb (for IDA),

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104
Q

What classifies as a stillbirth (rather than a miscarriage)?

A

Foetus born with no signs of life >24 weeks of pregnancy

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105
Q

What is the difference between the perinatal and neonatal mortality rate?

A

Perinatal = stillbirths + deaths within 1st week, whereas neonatal = deaths of live-born infants in first 4 weeks after birth

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106
Q

For how long is a baby considered a neonate?

A

Up to 28 days old

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107
Q

What is considered ‘term’?

A

27-41 weeks old

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108
Q

Recall the cutoff rates for low, very low and extremely low birthweight

A

Low = <2500g
Very low = <1500
Extremely low = <1000

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109
Q

How is small/large for gestational age calculated?

A

Small = in <10th centile, large = >90th centile

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110
Q

What does a routine neonate inspection exam include?

A

Head to toe systematic:
1. Birthweight and gestational age
2. General observation - posture? Pallor? Rash?
3. Head (many things to look for)
4. Breathing and HR and peripheral saturations
5. Femoral pulses and genitalia
6. Musle tone, DDH, whole of back and spine, DDH/ Club feet?
7. Reflexes

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111
Q

What is being looked for upon examination of the neonatal head ?

A

Head circumference (macrocephaly?)
Eyes (red reflex?)
Cephalohematoma (benign, self-resolving)
Caput Succedaneum = Cross Suture lines (self-resolving)
Tense fontanelle (raised ICP?)
Depressed fontanelle (dehydrated?)

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112
Q

What are the primitive reflexes?

A

Moro
Stepping
Asymmetric tonic
Palmar
Babinski’s

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113
Q

What are the components of the test for DDH?

A

Barlow’s (abduct and push joint posteriorly)
Ortolani’s (lift and externally rotate)

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114
Q

What is the Guthrie test?

A

Biochemical screening

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115
Q

When should the Guthrie test be done?

A

At 7 days old

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116
Q

What is included in the Guthrie test?

A

Congenital hypothyroidism
SCD
CF
6 metabolic diseases:
- PKU
- MCADD
- Maple Syrup Urine disease
- IVA (isovaleric acidaemia)
- Glutaric aciduria type 1
- HCU (homocysteinuria )

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117
Q

Which type of infection can cause sensorineural hearing loss in neonates?

A

CMV

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118
Q

What is the 1st and 2nd line options for testing hearing at birth?

A

1st line: Evoked otoacoustic emission- If earphone doesn’t produce an echo…
2nd line: Automated auditory brainstem response- Computer analyses the EEG wave forms evoked in response to a series of clicks

119
Q

What features of FAS would be seen in the neonatal examination?

A

Microcephaly, absent philtrum, cardiac abnormalities, reduced IQ, IUGR, small upper lip

120
Q

What is the triad of features seen in Rubella syndrome?

A

Cataracts, deafness, cardiac abnormalities

121
Q

What abnormalities would be seen in a baby who is born to a mother with syphillis?

A

Saddle nose, rhinitis, deafness, hepatosplenomegaly and jaundice

122
Q

What is the NIPE and when should it be done?

A

Neonatal and infant Physical Examination

<72 hours AND 6-8 weeks

123
Q

What are the 4 major areas of the NIPE?

A

Heart, Eyes, Testes, Hips

124
Q

What is positional talipes, and what causes it?

A

Feet remaining in in-utero position, due to intrauterine compression

125
Q

How should positional talipes be managed?

A

Physiotherapy

126
Q

What is club foot known as medically?

A

Talipes equinovarus

127
Q

How should club feet be managed?

A

Ponsetti method (plaster casting and bracing)
Surgery if severe

128
Q

What is the cause of hypoxic ischaemic encephalopathy ?

A

Perinatal asphyxia - may be due to placental abruption, interruption of umbilical blood flow (eg shoulder dystocia –> cord compression), maternal hypotension, IUGR or failure to breathe at birth

129
Q

If hypoxic ischaemic encephalopathy continues post-natally, what will it cause?

A

Cerebral palsy

130
Q

What are the key features of mild hypoxic ischaemic encephalopathy ?

A

Staring eyes, hyperventilation, hypertonia

131
Q

What are the key feature of moderate hypoxic ischaemic encephalopathy ?

A

Cannot feed, possible seizures, hypotonic

132
Q

What are the key features of severe hypoxic ischaemic encephalopathy ?

A

No normal movement in response to pain, tone fluctuates between hypertonic and hypotonic, seizures refractory to treatment, MODS

133
Q

How should hypoxic ischaemic encephalopathy be managed?

A

Supportively
Resp support, anticonvulsants, fluid restriction (transient renal impairment), inotropes (to treat hypotension), therapeutic hypothermia (requires NICU)

134
Q

At what age does brain injury classify as ‘acquired brain injury’ and not cerebral palsy?

A

2 years old

135
Q

How can cerebral palsy be aquired post-natally?

A

Perventricular leukomalacia secondary to ischaemia (eg meningitis, very prem birth)

136
Q

Recall some features of abnormal posture/tone due to cerebral palsy

A

Stiff legs which scissor
Hypotonia or spasticity
Inability to lift head
Rounded back when sitting
Fisted hands

137
Q

Other than postural/ limb tone abnormalities, what abnormalities might be seen in cerebral palsy?

A

Feeding difficulties, abnormal gait, hand preference before 1 year old

138
Q

How is gross motor function classified?

A

GMFCS (gross motor funtion classification system!)

139
Q

What are the subtypes of cerebral palsywith their relative prevalences?

A

Spastic CP (90%) Dyskinetic CP (6%)Ataxic CP (4%)

140
Q

What is the cause of spastic cerebral palsy?

A

Damage to UMN pathway (pyramidal tracts)

141
Q

What is one of the pathognomonic features of spastic cerebral palsys opposed to other types of cerebral palsy?

A

Clasp knife rigidity - increased tone suddenly gives way under pressure

142
Q

What are the 3 main types of spastic cerebral palsy?

A

1) unilateral/ hemiplegia:
- unilateral arm and leg, face spared
- tiptoe walk on affected side
- likely to have an unremarkable management and birth
2) BL/ quadriplegia: all 4 limbs, often severe
- poor head control –> low central tone + seizures - often have LD
3) Diplegia (legs affected to a greater degree)
- Abnormal walk
- Associated with pre-term birth damage

143
Q

What are the possible causes of dyskinetic cerebral palsy?

A

HIE or kernicterus

144
Q

What is kernicterus?

A

Brain damage due to hyperbilirubinaemia

145
Q

Describe the phenotype of dyskinetic cerebral palsy

A

Variable muscle tone predominated by primitive motor reflexes:
- Chorea
- Athetosis (fanning fingers)
- Dystonia (twisted appearance)

146
Q

What is the cause of ataxic cerebral palsy?

A

Damage to cerebellum - most geneticly determined

147
Q

How should cerebral palsy be investigated?

A

History, clinical examination and developmental progress - if cause is not clear, MRI

148
Q

What one clinical sign is always an indication for referral for cerebral palsy investigation?

A

Persistent toe walking

149
Q

What are some red flags for other neurological conditions when considering a diagnosis of cerebral palsy?

A

Absence of other risk factors
FHx of progressive neurological disorder
Loss of already attained cognitive/ developmental abilities
MRI suggestive of progressive neurological disorder

150
Q

How should cerebral palsy be managed?

A

Very MDT orientated
- Info about prognosis: eg children who can sit by age 2 are likely to be able to walk unaided by 6
- SCOPE disability charity
- Medication: stiffness = diazepam, sleeping = melatonin, constipation = movicol, drooling = anticholinergic

151
Q

Recall some important things to say in PACES counselling of a cerebral palsy child’s parents

A

Explain that brain damage has occurred in early development
Explain that damage doesn’t get worse, but will change its manifestation as the child gets older
Refer to MDT - especially paediatrician
Longterm management = physiotherapy, SALT and SEN
Medication options

152
Q

Which babies are at highest risk of developing NEC?

A

Premature/ LBW

153
Q

What is the aetiology of NEC?

A

Mostly unknown but thought to be a combination of poor blood flow and infection

154
Q

What are the early signs of NEC?

A

Biliary vomiting (green), feeding intolerance

155
Q

What will be seen on AXR in NEC?

A

Gas cysts

156
Q

What are the appropriate investigations to do in NEC?

A

AXR
Blood cultures

157
Q

What are the criteria used to decide management of NEC?

A

Bell’s staging

158
Q

Recall the elements of NEC management

A
  1. Bowel rest - stop oral feed and switch to parenteral nutrition
  2. Broad-spectrum Abx (eg Tazocin) - number of days depends on stage
  3. Laparotomy (if perforation is seen on AXR)
159
Q

Give some reasons for physiological jaundice at birth

A
  1. Hb release from RBCs as there is a high [Hb] at birth
  2. RBC lifespan being 70 days rather than 120 days
  3. Breast milk jaundice (but not until after >24 hours)
  4. BR metabolism being less efficient in first few days of life
160
Q

What is the main danger of uBR buildup in neonates?

A

Kernicterus (a form of encephalopathy): it’s caused by a deposit of uBR in the basal ganglia
May develop into dyskinetic CP, LD and sensorineural deafness

161
Q

How can uBR buildup in neonates be treated before any damage is done?

A

Phototherapy +/- IvIG and exchange transfusion

162
Q

What would be the difference in clinical presentation between uBR buildup and cBR buildup?

A

uBR buildup –> kernicterus
cBR buildup –> dark urine and pale stools

163
Q

In what situations should phototherapy be stopped?

A

If bronzing occurs: it means the child has a buildup of cBR, rather than uBR, which cannot be treated using phototherapy

164
Q

How should investigations begin in neonatal jaundice?

A
  1. Check transcutaneous or serum BR levels
  2. Do a split BR to check uBR/cBR
  3. May want to do a blood film analysis
165
Q

Recall some pathological causes of neonatal jaundice in babies <24 hours old

A

GRAPHIC DOG
- Gilbert’s
- Rhesus disease
- ABO incompatability (–> haemolysis)
- PK deficiency
- Hereditary spherocytosis
- Infection
- Crigler-Najjar
- Dubin-Johnson
- Other…
- G6PD deficiency

166
Q

Recall 3 physiological causes of jaundice in a 2 day to 2 week old baby

A

Physiological jaundice
- due to immature liver, peaks at 3-5 days
Breastfeeding jaundice
- less milk intake –> more enterohepatic recycling
Breastmilk jaundice
- Decreased UGT1A1 activity (occurs following physiological jaundice)

167
Q

What haemolytic and metabolic causes for jaundice might present in a 2 day to 2 week old baby?

A

Metabolic = Gilbert’s, Crigler-Najjar, Dubin-Johnson
Haemolytic: G6PDD, PK deficiency, hereditary spherocytosis (less likely to be ABO at this point)

168
Q

What may be the cause of jaundice in a 2 day to 2 week old baby that didn’t present in first 24 hours?

A

Congenital hypothyroidism
Dehydration
Bruising (cephalohematoma)
Polycythaemia

169
Q

How should jaundice be investigated in a baby over 2 weeks old?

A

Direct and indirect serum BR

170
Q

Which of the conditions that cause jaundice in a 2 day to 2 week old baby might continue to the >2 weeks stage?

A

All - but physiological and breastmilk is most common

171
Q

Recall 2 further causes of a buildup of uBR in a baby over 2 weeks old

A

Pyloric stenosis (presents at 2-4 weeks)
Congenital hypothyroidism*

172
Q

Systematically recall the causes of a raised cBR in the neonate (>2w old)

A

Endocrine: Congenital hypothyroidism

GI: Billiary atresia, ascending cholangitis (can be caused by lipids on TPN)

Metabolic: Gal-1-PUT, A1AT deficiency, Tyrosinaemia type 1, peroxisomal disease

Other: CF, idiopathic neonatal hepatitis

173
Q

For how long does jaundice have to persist in order to be defined as ‘prolonged’?

A

> 14 days if term
21 days if pre-term

174
Q

At what age should investigations include a split BR rather than just a total BR?

A

2 weeks

175
Q

What is a worrying BR in a baby >37w gestation (red flag for kernicterus)?

A

> 340

176
Q

Recall the clinical features of kernicterus

A

Poor feeding, extreme letahrgy, hypotonia, high-pitched cry

177
Q

Recall some investigations you might do to find the underlying cause of jaundice in a baby

A

TC/ serum BR within 6 hours of presentation

Haematocrit

DAT/ Coombs (haemolysis?)

G6PD levels (depending on ethnic origin)

TSH (hypothyroid?)

LFTs (ascending cholangitis? Biliary atresia?)

Blood group of M and B (ABO incompatible? Rhesus?)

Blood film + osmotic fragility (hereditary spherocytosis?)

MC&S of urine/ CSF (if ? infection cause)

178
Q

How is treatment of neonatal jaundice guided?

A

There are thresholds at which phototherapy/ exchange transfusion are indicated

179
Q

What are the options for treatment of neonatal jaundice?

A

Phototherapy +/- IV Ig
Exchange transfusion + phototherapy +/- IV Ig

180
Q

How does phototherapy work?

A

Converts uBR to a water-soluble pigment that is excreted in urine

181
Q

What important checks should be done during/ after phototherapy?

A

During: temperature, BR levels every 4-6 hours (with regular feed breaks)
After (12-18 hours post): check for a rebound hyperbilirubinaemia

182
Q

When should intensive phototherapy be given?

A
  1. Rapidly rising BR
  2. Serum BR within 50mmol of exchange tranfusion threshold (after 72 hours life)
  3. BR level doesn’t respond after 6 hours of therapy
183
Q

What are the 2 indications for exchange transfusion to treat neonatal jaundice?

A
  1. BR threshold reached
  2. Signs of kernicterus
184
Q

What is an important thing to remember when giving an exchange transfusion?

A

Give folic acid afterwards to prevent anaemia

185
Q

What is one thing to be cautious of if delivering high oxygen levels to a neonate?

A

Retinopathy of prematurity

186
Q

Recall some signs of respiratory distress in babies

A

High RR (>60)
Laboured breathing
Chest wall recessions
Nasal flaring
Expiratory grunting
Cyanosis (if severe)

187
Q

What is the most common cause of respiratory distress in term infants?

A

Transient tachypnoea of the neonate

188
Q

Recall 4 conditions that PPHTN can be secondary to

A

Birth Asphyxia
Meconium aspiration
Septicaemia
RDS

189
Q

What is the pathophysiology of PPHTN?

A

High pulmonary vascular resistance –> right to left shunting within lungs at atrial and ductal levels

190
Q

Recall some signs and symptoms of PPHTN

A

Cyanosis after birth
Absent heart murmurs and signs of HF

191
Q

What investigations are appropriate in PPHTN and what would they show if pos?

A

CXR: normal heart size but some pulmonary oligaemia
Echo: to ensure no cardiac defect

192
Q

How should PPHTN be treated?

A

Oxygen, NO (inhaled), sildenafil (!!) Ventilation: mechanical, high frequenct (oscillatory) OR, if severe, extracorporeal membrane oxygenation (ECMO) +/- heart/lung bypass

193
Q

What is the cause of TTotN?

A

Delay in resorption of lung fluid

194
Q

How is a diagnosis of TTofN made?

A
  1. CXR - shows fluid in horizontal fissure
  2. Other causes excluded
195
Q

What are the possible causes of paediatric chronic lung disease?

A

Infection, barotrauma, iatrogenic injury

196
Q

What is the pathophysiology of paediatric chronic lung disease?

A

Lung damage due to pressure and volume trauma from artificial ventilation, O2 toxicity and infection

197
Q

What are appropriate investigations in paediatric chronic lung disease and what would pos results show?

A

CXR: widespread opacification

CBG/VBG: acidosis, hypercapnia, hypoxia

198
Q

How can paediatric chronic lung disease be managed?

A

Respiratory support (!): prolonged artificial ventilation –> wean to CPAP –> wean to additional O2

Corticosteroid therapy - dexamethosone is useful for short-term clinical improvement (but concerns limit use)

199
Q

What is the cause of RDS in neonates?

A

Deficiency of surfactant (common if born <28 weeks gestation)

200
Q

Recall some risk factors for RDS

A

DM mother
2nd born of premature twin

201
Q

How is RDS diagnosed?

A

It’s a clinical diagnosis
Can be supported by:
- Pulse oximetry
- CXR showing pneumothorax (from ventilation), ground-glass appearance

202
Q

How can RDS be managed antenatally and postnatally?

A

Antenatal: steroid therapy + tocolytic therapy so steroids have at least 24 hours to work
Postnatal: oxygen and ventilation (caution: CLD), CPAP

203
Q

What is the cause of pneumothorax in children, and what is the best way to prevent them?

A

Ventilation which causes pulmonary interstitial emphysema

Can be prevented that infants are ventilated on the lowest possible pressures with adequate chest movement and blood gaes

204
Q

How should infant pneumothorax be treated?

A

Immediate decompression
Oxygen therapy
Chest drain if tenion pneumothorax

205
Q

When does meconium aspiration occur?

A

Exclusively in immediate neonatal period

206
Q

What is the biggest RF for meconium aspiration?

A

Increased GA

207
Q

What are the signs and symptoms of meconium aspiration?

A

Respiratory distress, chest retraction, hypoxia

208
Q

How is meconium aspiration diagnosed?

A

CXR: shows overinflated lungs, patches of collapse and consolidation
May show pneumothorax or pneumomediastinum (from air leak)

209
Q

How is meconium aspiration managed?

A

Observation: there will be meconium-stained amniotic fluid and no history of GBS

IV ampicillin and IV gentamicin (to treat features of infection)

CPAP (for severe cases)

210
Q

What is meconium ileus?

A

Thick, sticky meconium that has a prolonged passing time

211
Q

What is the normal period of delivery of meconium?

A

Within 24 hours

212
Q

Recall 2 associations of meconium ileus

A

CF
Biliary atresia

213
Q

How should meconium ileus be managed?

A

1st line: Gastrograffin enema
2nd line: surgery

214
Q

Recall some differentials for billious vomiting in the neonate

A

NEC
Duodenal/ jejunal/ ileal atresia
Meconium ileus
Malrotation volvulus

215
Q

What is the most important investigation to do in investigating billious vomiting, and what results might it show?

A

AXR: “Double bubble” sign = duodenal atresia
Air-fluid levels - jejunal/ ileal atresia
Dilated bowel loops –> NEC

216
Q

How are duodenal/ jejunal/ ileal atresia managed?

A

Duodenal atresia –> duodenoduodenostomy
Jejunal/ ileal atresia –> laparotomy

217
Q

How is malrotation volvulus managed?

A

Ladd’s procedure

218
Q

When does malrotation volvulus present, and how is it diagnosed?

A

3-7 days
Upper GI contrast or USS

219
Q

What is the pathophysiology of cleft lip/ palate?

A

Failure of fusion of the frontonasal and maxiliary processes

220
Q

Recall one condition that babies with cleft lip/ palate are at an increased risk of

A

Secretory otitis media

221
Q

Recall 2 maternal risk factors for cleft lip/ palate

A

Antiepileptic/ BDZ use

222
Q

What are some pre-surgical concerns to bear in mind in cleft lip/ palate?

A

Specialised feeding
Watch out for aiway problems
Pre-surgical lip-tapping/ nasal alveolar modelling to narrow cleft

223
Q

What is the name for a left-sided diaphragmatic hernia?

A

Bochdalek hernia

224
Q

When does diaphragmatic hernia form in utero?

A

At around 6-8 weeks gestation

225
Q

Recall 2 factors affecting prognosis in diaphragmatic hernia

A
  1. Liver position
  2. Lung-to-head ratio
226
Q

What are the signs and symptoms of diaphragmatic hernia?

A

Respiratory distress at delivery
Concave chest at birth

227
Q

How is diaphragmatic hernia diagnosed?

A

Routine USS following resp distress at birth

228
Q

What does CXR show in diaphragmatic hernia?

A

mediastinum displaced to left, collapsed left lung, bowel loops in thorax

229
Q

Recall the 1st and 2nd line management options for diagphragmatic hernia management

A

1st: NG tube and suction - prevents distention of intrathoracic bowel and allows breathing

2nd: Surgical reduction and repair, allowing re-expansion of the lung
- TPN/ ventilation needed for recovery

230
Q

What is oesophageal atresia?

A

Malformation of the oesophagus so that it does not attach to the stomach

231
Q

What is tracheo-oesophageal fistula?

A

Part of the oesophagus is joined to the trachea - often occurs alonsgide OA

232
Q

What is the main risk of oesophageal atresia/ tracheo-oesophageal fistula?

A

Stomach acid can regurgitate into the lungs causing CLD/ BPD (bronchopulmonary dysplasia)

233
Q

How will amniotic fluid be affected by a TOF that is preventing swallow?

A

Polyhydramnios

234
Q

How should tracheo-oesophageal fistula/ oesophageal atresia be investigated?

A

NG tube to aspirate the stomach contents can quickly confirm or exclude

The gold standard = gastragaffin swallow

235
Q

Recall the management of oesophageal atresia/ tracheo-oesophageal fistula

A
  1. Replogle tube to drain saliva from oesophagus
  2. Surgical repair (within a few days of birth) followed by NICU and ventilator support
236
Q

What is biliary atresia?

A

Progressive fibrosis and obliteration of extra- and intra-hepatic trees, leading to chronic liver failure in 2 years

237
Q

What are the subtypes of biliary atresia?

A

T1 - common bile duct atresia
T2 - cystic duct atresia
T3 - full atresia (>90%)

238
Q

What are the signs and symptoms of bililary atresia?

A

Obstructive jaundic picture (pale stools, dark urine) with no vomiting
Hepatosplenomegaly
Normal BW –> faltering growth

239
Q

Once a raised cBR has been identified, how can biliary atresia be diagnosed? What, then, is the gold standard?

A

USS showing triangular cord sign
LFT shows raised GGT
Gold standard: TIBIDA isotope scan (radioisotope scan of bile secretion) confirmed by ERCP and biopsy

240
Q

What is the 1st-line management of biliary atresia?

A

Kasai hepatoportoenterostomy
Ligate fibrous ducts abive the join with the duodenum
Join an end of the duodenum directly to the porta hepatis of the liver
If unsuccessful –> transplant

241
Q

How are the complications of biliary atresia managed?

A

Fat-soluble vitamins (as bile ducts affected)
Usodeoxycholic acid (this promotes bile flow)
Prophylatic Abx (to prevent cholangitis - cotrimoxazole)

242
Q

What is small bowel atresia?

A

Congenital absence or complete closure of part of the lumen of the small bowel

243
Q

Recall 3 associations of duodenal atresia

A

Congenital cardiac abnormalities
Down’s
Polyhydramnios

244
Q

What are the signs and symptoms of small bowel atresia?

A

Bile-stained vomiting is the main one

If non-bilious it may be duodenal rather than jejunal/ ileal

Abdominal distention

245
Q

How should small bowel atresia be managed?

A

ABCDE to stabilise neonate+/- NG tube decompression
Surgical:
- primary anastomosis or LADD procedure if malrotation is present
- Need to examine the whole bowel while you’re at it to exclude other multiple atretic segments

246
Q

What is the main gene implicated in CAKUT?

A

PAX 2

247
Q

Recall 4 renal conditions of CAKUT

A

Multicystic kidneys
Renal agenesis
Medullary sponge kidney
Horseshoe kidney

248
Q

Recall 3 non-renal conditions of CAKUT

A

Pelvouteric junction obstruction
Vesicoureteral reflux (in 30% of children presenting with UTIs)
Bladder outlet obstruction

249
Q

Recall some antenatal signs of CAKUT

A

Oligohydramnios
Decreaed foetal UO

250
Q

Recall some postnatal signs of CAKUT

A

Often present with UTI
Intra-abdominal mass
Haematuria
Renal calculi/ renal failure
Hepatosplenomegaly

251
Q

What is Potter’s sequence?

A

BL renal agenesis
Abnormal facies (widely separated eyes, low set ears, receding jaw)
Caused by OLIGOHYDRAMNIOS

252
Q

Recall five important investigations you could do when looking for a cause of CAKUT

A

Renal USS
DMSA scan (Tc-99) - detects scarring and functional defects
MCUG (micturating cystourethrogram) - visualises anatomy (would see VUR)
MAG3 renogram (also Tc-99) - dynamic screen shows MAG3 being excreted into urine using furosemoide
Genetic karyotyping

253
Q

What are some signs of an atypical UTI?

A

Poor UO
Sepsis
Abdo/bladder mass
Failure to respond in <48 hours
Raised creatinine
Infection with non-E coli organisms

254
Q

How do you choose which investigation to use in UTI?

A

If atypical UTI, recurrent UTI, or first UTI
<6m: Renal USS
If recurrent UTI or atypical UTI <3 years old: DMSA scan
If VUR is suspected on USS, obstruction or trauma: MCUG/ VCUG

255
Q

What is the pathophysiology of VUR?

A

The ureters enter the bladder perpendicularly –> shorter intramural course –> VUR

256
Q

What is the main factor affecting prognosis of VUR?

A

Whether there’s a renal cause or not: renal causes have a bad prognosis but non-renal causes have a pretty good prognosis if treated

257
Q

What are the types of anorectal malformation, and how can you tell the difference between them?

A

Low anorectal anomaly = anus closed over - in a different position or narrower than usual + fistula to skin
High anorectal anomaly - bowel has closed end at high level, not connecting with anus - fistula is usually to bladder/ urethra/ vagina

258
Q

What are the symptoms of anorectal malformation?

A

Absent/ delayed meconium
Swollen abdomen
Vomiting
If there’s a fistula they may pass stool from an abnormal area

259
Q

How should anorectal malformation be investigated?

A

Checked on neonatal check - it’s a clinical diagnosis

260
Q

How is anorectal malformation managed in babies?

A

Surgical correction by 9 months

261
Q

What is the normal period of time in which the testes descend?

A

Usually by 3m but can be up to 6m

262
Q

At what point should a referral to a paediatric surgeon be made, if there is UL testicular undescent?

A

3 months

263
Q

At what point should a referral to a paediatric surgeon be made, if there is BL undescent of testes?

A

May have a pituitary cause so immediately refer to paeds/ endo

264
Q

What are the medical and surgical management options for cryptorchidism?

A

Medical: beta-hCG (may or may not be given)
Surgical: orchidopexy

265
Q

What is billious vomit a red flag for?

A

Intestinal obstruction (intussusception, malrotation, strangulated inguinal hernia)

266
Q

What is haematemesis a red flag for?

A

Oesophagitis/ PUD

267
Q

What is projectile vomit at 2-7 weeks a red flag for?

A

Pyloric stenosis

268
Q

What is vomiting at end of paroxysmal coughing a red flag for?

A

Whooping cough

269
Q

What is abdo distention a red flag for in a baby?

A

Intestinal obstruction/ strangulated inguinal hernia

270
Q

What is hepatosplenomegaly a red flag for?

A

Chronic liver disease, inborn error of metabolism

271
Q

What is blood in stool a red flag for?

A

Intussusception, gastroenteritis (salmonella, campylobacter)

272
Q

What are bulging fontanelles/ seizures a red flag for?

A

Raised ICP

273
Q

What is a failure to thrive a red flag for?

A

GORD, coeliac, chronic GI

274
Q

What is chronic vomiting in an infant most likely to be due to?

A

GORD or a feeding problem

275
Q

What is transient vomiting in a child most likely to be due to?

A

Gastroenteritis, URTI

276
Q

What needs to be excluded urgently when an infant is vomiting?

A

Meningitis and UTI

277
Q

What is a failure to pass meconium in first 24 hours a red flag for?

A

Hirschprung’s

278
Q

What is FTT/ growth failure a red flag for in a constipated child?

A

Hypothyroid/ coeliac

279
Q

What is gross abdo distention with constipation a red flag for?

A

Hirschprung’s/ other GI dysmotility

280
Q

What is abnormal LL neurology/ deformation a red flag for?

A

Lumbosacral pathology

281
Q

What is a red flag for spina bifida?

A

Sacral dimple above nasal cleft

282
Q

What is perianal fistula/ abscess/ fissure a red flag for in infants?

A

Perianal Crohn’s

283
Q

What is the normal feed pattern in newborns?

A

45-90ml per 2-3 hours

284
Q

What is the normal feed pattern in a 2 month old?

A

120-150mls per 3/4 hours

285
Q

What is the normal feed pattern in a 6 month old?

A

Solids should be being introduced

286
Q

By what age should bowel habit be similar for a child as an adult?

A

4 years

287
Q

Recall the most common complication of long-standing constipation in children

A

Overdistention –> lose feeling needed to defaecate –> involuntary soiling with overflow

288
Q

How can constipation be treated in children?

A

Stool softeners (eg movicol)
If unsuccessful consider stimulant laxatives (eg senna)
Movicol can be used as a maintenance therapy

289
Q

How is constipation diagnosed in a child?

A

2+ of the following:
- <3 complete stools per week
- Hard, large stool or ‘rabbit dropping’
- Overflow soiling 1+ year
- Distress, pain, bleeding associated with stool

290
Q

Recall the management protocol for paediatric status epilepticus

A
  1. ABC
  2. Check blood glucose - if <3mmol/L –> IV glucose and then re-check
  3. If vascular access –> IV lorazepam
    If no vascular access –> PR diazepam/ buccal midazolam
  4. If IV access: More lorazepam
    If still no IV access - PR paraldehyde
  5. If previously had IV access to give IV lorazepam but it hasn’t worked, try PR paraldehyde
  6. If no response in 10 mins call for senior help
    If not on oral phenytoin: phenytoin
    If already on oral phenytoin: phenobarbital
  7. If no response within 20 mins, call anaesthetist/ intensivist –>
    Induction with thiopental
    Mechanical ventilation
    –> PICU
291
Q

What is the dose per kg of lorazepam to give to children in status epilepticus?

A

0.1mg/kg

292
Q

What is the dose per kg of diazepam to give to children in status epilepticus?

A

0.5mg/kg

293
Q

What are some postural reflexes?

A

Labyrinthine righting: head moves in opposite direction to which the body is tilted
Postural support: legs take weight when held upright
Lateral propping: when sat, arm extends to take weight
Parachute: arms extend when suspended down

around 4-12 months

294
Q

How does cognitive thinking develop?

A

pre-operational thought in preschool: centre of world, objects have feelings + motive, everything has a purpose
operational thought: practical orderly based on immediate circumstances
formal operational thinking: abstract reasoning, testing hypotheses and manipulating abstract concepts

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