Paeds IV Flashcards
How can you predict that might have a pre-term birth? [2]
Antenatally:
Prediction of pre-term birth
Fetal fibronectin:
- protein that helps the amniotic sac attach to the uterine lining during pregnancy. A fetal fibronectin test measures the amount of fFN in vaginal fluid to assess the risk of preterm birth.
Cervical length
- in singleton pregnancies a cervical length of < 25mm at < 23weeks + 6 days is associated with an increased risk of preterm birth
Describe the perinatal optimisation care pathway with regards to the perinatal period [4]
Place of birth:
- Level 3 units have better outcomes than level 2 /1. Better to transfer in-utero
Antenatal steroids
- Reduce risk of intraventricular haemorrhage
- Reduce risk of resp distress syndrome
MgS
- Reduces risk of cerebral palsy
Abx:
- Reduces poor outcomes
From Ward Poster
Describe the perinatanl pre-term optimisation plan [9]
Place of birth:
- All babies < 27 weeks or EFW < 800 g should be born in a NICU
MgS:
- Women giviing birth < 30 weeks should receive a loading dose and ideally a 4hr transfusion in the 24hrs before birth
Optimal cord management:
- umbilical cord clamped at or after one minute of birth
Breast milk:
- All babies should receive mother’s milk within 24hrs and ideally within 6
Caffeine:
- Give to babies < 30 weeks within 24hrs
Antenatal steroids:
- < 34 weeks, try and give a full course at least 7 days prior to birth
Prophylactic Abx:
- Give during labour
Thermal care:
- Take temp within one hour and should be between 36.5 and 37.5
Resp management:
- When conventional ventilation is appropriate, volume targeted ventilation should be used as initial mode of ventilation to avoid lung injury
Golden Hour: admission ot the neonatal unit:
- What should you do / control? [5
- Which medications should be given [6]
Resp. management
Access/Fluids
Early colostrum
- encourage mum so can give ASAP
Temp control and incubator humidity
Monitoring, NG and admission swabs
Medications:
* Caffeine
* Vit K
* Abx
* Hydrocortisone
* Prophylactic fluconazole
* Probiotics
Chest x-rays and USs
What is the benefit of giving caffeine to neonates? [2]
Stimulant so reduces the risk of apneas.
Can also cause improved neurodevelopment outcomes
Describe a risk of giving ventilation in neonates [1]
Too much ventilation:
- Blow off CO2: impacts cerebral circulation and increase risks of brain injury
Describe what a CXR of RDS looks like [2]
Ground glass shadowing with air bronchograms
AKA hyaline membrane disease
Name 4 risk factors for respiratory distress syndrome [4]
- male sex
- diabetic mothers
- Caesarean section
- second born of premature twins
How do you manage RDS? [4]
Management
* prevention during pregnancy: maternal corticosteroids to induce fetal lung maturation
* oxygen
* assisted ventilation
* exogenous surfactant given via endotracheal tube
How can you predict mean BP from a babys gestation? [1]
Mean BP matches their gestation
What are typical calories needs per day for a baby? [1]
120-150 ml/kg per day
Describe the pathophysiology of NEC [1]
What are the differences in neonate intestines that make them at an increased risk? [5]
The pathophysiology of NEC is not fully understood. But perhaps the most significant contributing factor in the development of NEC is intestinal immaturity. The characteristic differences in neonatal intestines compromise multiple gastrointestinal protective factors:
* Reduced gastric acid production
* Reduced intestinal barrier
* Immature immune function
* Immature digestion
* Immature motility
This intestinal immaturity is compounded by abnormal intestinal microbiota due to the frequent use of antibiotics in neonatal care. This culminates in an excessive inflammatory response leading to tissue injury and intestinal necrosis.
Describe the presentation of NEC:
- symptoms [5]
- signs / exam findings [5]
Premature baby:
- developing feeding intolerance
- vomiting
- lethargy
- abdominal distension
- progresses into bloody stools at around 9 days of age.
Signs:
* Shiny distended abdomen
* Periumbilical erythema
* Abdominal tenderness
* Bilious gastric aspirate
* Shock
What are the different stages of Bells staging criteria for NEC with regards to signs [3]
Stage 1: Suspected NEC
* Lethargy
* apnoea
* temperature instability
* abdominal distention
* vomiting
* heme-positive stool
Stage II: Proven NEC
- Similar to stage I with abdominal tenderness, abdominal wall discolouration, abdominal mass, mild metabolic acidosis
Stage III: Advanced NEC:
- Critically ill neonate with hypotension
- bradycardia
- peritonitis
- respiratory and metabolic acidosis,
- disseminated intravascular coagulation
What are the different stages of Bells staging criteria for NEC with regards to radiological signs [3]
Stage 1: Suspected NEC
- Intestinal dilation / normal
Stage II: Proven NEC
- Intestinal dilation
- ileus
- ascites
- pneumatosis intestinalis
Stage III: Advanced NEC:
- Pneumoperitoneum
Describe how you investigate for NEC [3]
Abdominal radiography is central to NEC diagnosis. Radiological findings which are pathognomic of NEC include:
* Pneumatosis intestinalis (seen as gas in the bowel wall on x-ray - mottled / soap bubble appearance
* Portal vein gas
Other radiographical signs which can support a diagnosis of NEC include:
* Dilated bowel loops
* Absence of bowel gas
* Persisting gas-filled bowel loops
* Pneumoperitoneum can be seen in advance NEC - Riglers sign
* (American) Football sign
Bloods:
- A rapid decrease in neutrophil count, platelet count or white cell count or persistently high C-reactive protein can indicate disease progression.
What does this x-ray show in NEC? [1]
Portal venous gas
How would you distinguish NEC from intestinal perforation of the newborn? [3]
Differences:
* Abscence of pneumatosis intestinalis on abdominal xray
* Blue discolouration of abdominal wall
* Occurs in first week of life
How do you manage NEC? [4]
Neonatal emergency:
* Abdominal decompression via nasogastric tube insertion
* Bowel rest via total parenteral nutrition
* Broad-spectrum intravenous antibiotics- - Generally consisting of a penicillin, gentamicin and metronidazole
* Surgical management options (if perforation is suspected or the infant is deteriorating): Peritoneal drain; Laparotomy with resection of necrotised bowel and enterostomy with stoma creation
What are the two types of Pre-term brain injury? [2]
How and when do you monitor for this? [+]
Preterm brain injury:
* intraventricular haemorrhage
* periventricular leukomalacia
Screen cranial US at:
- 1, 3 & 7 days
- 2-4 weekly until discharge
Describe the pathophysiology of intraventricular haem. [2]
When does it typically occur? [1]
In neonatal practice the vast majority of IVH occur in the first 72 hours after birth, the aetiology is not well understood and it is suggested to occur as a result of birth trauma combined with cellular hypoxia, together the with the delicate neonatal CNS.
Occurs due to fragile BV x poor autoregulation of cerebral blood flow
Describe 4 risks for IVH [4]
Reducing GA
Lack of perinatal optimisation
Chorioamnitis
Early haemodynamic instabilty
The retina is divided into three zones. What are they? [3]
Zone 1 includes the optic nerve and the macula
Zone 2 is from the edge of zone 1 to the ora serrata, the pigmented border between the retina and ciliary body
Zone 3 is outside the ora serrata
NB: The retinal areas are described as a clock face, for example “there is disease from 3 to 5 o’clock”. The areas of disease are described from stage 1 (slightly abnormal vessel growth) to stage 5 (complete retinal detachment).
“Plus disease” describes additional findings, in ROM, such as: [2]
“Plus disease” describes additional findings, such as tortuous vessels and hazy vitreous humour.
Which babies are screened for ROM? [2]
How often does screening occur? [1]
What does screening involve? [1]
All babies < 1500g or 31/40 are screen
4 – 5 weeks of age in babies born after 27 weeks
Screening should happen at least every 2 weeks and can cease once the retinal vessels enter zone 3, usually at around 36 weeks gestation.
Screening involves monitoring the retinal vessels as they develop and looking for plus disease.
How do you treat ROM? [4]
First line is transpupillary laser photocoagulation to halt and reverse neovascularisation.
Other options are cryotherapy and injections of intravitreal VEGF inhibitors.
Surgery (vitrectomy) may be required if retinal detachment occurs.
What are some longer term complications of being premature? [5]
PDA
Chronic lung disease of prematurity
ROM
Neurodisability: hearing impairment and oral aversion
Neurodiversity
A baby is deemed high risk with chronic lung disease. What management might you consider for them? [1]
RSV prophylaxis
What are risk factors for cot death? [4]
How do you instruct babies to sleep? [1]
Risk factors:
- exposure to tobacco smoke
- late or no antenatal care
- young maternal age
- premature birth
Instruct babies to ‘‘Back to sleep” - sleep on their backs to reduce likelyhood
What are the clinical featuers of meconium aspiration syndrome?
A typical presentation of meconium aspiration syndrome (MAS) may involve a term or post-term neonate displaying signs of respiratory distress shortly after birth:
Tachypnoea:
- Rapid breathing is one of the most common presenting features in MAS. It typically occurs within minutes to hours after birth.
Cyanosis:
- A bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood.
Decreased breath sounds or rales:
- Auscultation may reveal decreased breath sounds with rales or rhonchi due to airway obstruction by meconium.
Barrel-shaped chest:
- This may be present due to hyperinflation of the lungs from obstructive emphysema as a result of air trapping.
Prolonged expiratory phase:
- This can be noted on physical examination and is indicative of airway obstruction.
NB: It’s important to note that the severity of symptoms and findings can vary significantly between individuals. Some neonates with MAS may present with mild respiratory distress while others may develop severe respiratory failure requiring mechanical ventilation
How do you investigate for MAS?
- First line? [3]
First-line investigations
Chest X-ray:
- A chest radiograph is essential to evaluate the presence of infiltrates, atelectasis, or hyperinflation. Typical findings in meconium aspiration syndrome (MAS) include patchy areas of atelectasis and hyperinflation.
- The presence of air leaks such as pneumothorax or pneumomediastinum should also be assessed.
Arterial blood gas (ABG):
- ABG analysis is critical for assessing the degree of hypoxemia, hypercapnia, and acidosis.
- This helps gauge the severity of respiratory compromise and guides oxygen therapy and ventilation strategies.
Pulse oximetry:
- Continuous monitoring of oxygen saturation provides real-time data on the infant’s oxygenation status and helps in titrating supplemental oxygen levels.
NB: The diagnosis of MAS typically relies heavily on clinical presentation combined with radiographic evidence from chest X-rays. Further investigations are guided by specific clinical indications such as suspected PPHN or concurrent infections.
A baby presents with MAS and PPHN. What is the next appropriate investigation and why? [2]
Echocardiography:
- This investigation is indicated if there are signs suggestive of persistent pulmonary hypertension of the newborn (PPHN), which can coexist with MAS. Echocardiography evaluates pulmonary artery pressures, cardiac function, and excludes congenital heart disease.
Describe the management plan for a baby with MAS [4] and PPHN [2]
Initial stabilisation:
* Avoid routine intrapartum suctioning.
* If the neonate is vigorous (strong respiratory effort, good muscle tone, heart rate >100 bpm), proceed with standard neonatal care.
* If the neonate is not vigorous: perform direct laryngoscopy and tracheal suctioning to remove meconium from the airway before initiating positive pressure ventilation (PPV).
Respiratory support:
* Administer supplemental oxygen to maintain target oxygen saturation levels as per neonatal resuscitation guidelines.
* Initiate continuous positive airway pressure (CPAP) or mechanical ventilation if indicated by respiratory distress or hypoxaemia.
Surfactant therapy:
* Consider administration of exogenous surfactant in cases of severe respiratory distress or when mechanical ventilation is required.
Antibiotic therapy:
* Initiate empirical antibiotic therapy due to the risk of secondary bacterial infection. Adjust based on culture results and clinical course
Management of persistent pulmonary hypertension (PPHN):
* Employ inhaled nitric oxide (iNO) for infants with significant PPHN unresponsive to conventional ventilation and oxygen therapy.
* If iNO is unavailable or ineffective, consider extracorporeal membrane oxygenation (ECMO) as a last resort in specialised centres.
AVOID routine use of corticosteroids unless there are specific indications such as concurrent conditions requiring their use.
Describe the cardiac changes / process that happens directly at birth [4]
After first breath:
- decrease in pulmonary vascular resistance causes fall in pressure in right atrium
At this point:
- the left atrial pressure is greater than the right atrial pressure, which squashes the atrial septum and causes functional closure of the foramen ovale. The foramen ovale then structurally closes and becomes the fossa ovalis.
Prostaglandins are required to keep the ductus arteriosus open.:
- Increased blood oxygenation causes a drop in circulating prostaglandins. This causes closure of the ductus arteriosus, which becomes the ligamentum arteriosum.
Describe the respiratory changes / process that happens directly at birth [4]
During birth the thorax is squeezed as the body passes through the vagina, helping to clear fluid from the lungs
Birth, temperature change, sound and physical touch stimulate the baby to promote the first breath.
- A strong first breath is required to expand the previously collapsed alveoli for the first time
Adrenalin and cortisol are released in response to the stress of labour, stimulating respiratory effort
The first breaths the baby takes expands the alveoli, decreasing the pulmonary vascular resistance. The decrease in pulmonary vascular resistance causes a fall in pressure in the right atrium
Pulmonary hypoplasia is a term used for newborn infants with underdeveloped lungs
Causes include
[2]
Pulmonary hypoplasia is a term used for newborn infants with underdeveloped lungs
Causes include
oligohydramnios
congenital diaphragmatic hernia
Describe in detail the principles of neonatal resusciation [2]
Warm The Baby:
- Get the baby dry as quickly as possible. Vigorous drying also helps stimulate breathing.
- Keep the baby warm with warm delivery rooms and management under a heat lamp
- Babies under 28 weeks are placed in a plastic bag while still wet and managed under a heat lamp
Calculate the APGAR Score
This is done at 1, 5 and 10 minutes whilst resuscitation continues
This is used as an indicator of the progress over the first minutes after birth
* It helps guide neonatal resuscitation efforts
Stimulate Breathing
* Simulate the baby to prompt breathing, for example by drying vigorously with a towel
* Place the baby’s head in a neutral position to keep airway open. A towel under the shoulders can help keep it neutral.
* If gasping or unable to breath, check for airway obstruction (i.e. meconium) and consider aspiration under direct visualisation
Inflation Breaths
- given when the neonate is gasping or not breathing despite adequate initial simulation.
- Two cycles of five inflation breaths (lasting 3 seconds each) can be given to stimulate breathing and heart rate
* If there is no response and the heart rate is low: 30 seconds of ventilation breaths can be used
* If there is still no response: chest compressions can be used, coordinated with the ventilation breaths
* Technique is very important in delivering effective inflation breaths. Get someone experienced to show you how to perform them. It is essential to maintain a neutral head position and get a good seal around the mouth and nose. Look for a rise and fall in the chest.
* When performing inflation breaths,** air should be used in term or near term babies**, and a mix of air and oxygen should be used in pre-term babies.
Chest Compressions
* Start chest compressions if heart rate remains below 60 bpm despite resuscitation and inflation breaths (see protocol)
* Chest compressions are performed at a 3:1 ratio with ventilation breaths
What are the scores used to calculate APGAR score?
Why is Vit K given at birth? [3]
Babies are born with a deficiency of vitamin K:
- Vitamin K helps to prevent bleeding, particularly intracranial, umbilical stump and gastrointestinal bleeding
NB: As Vit K is via injection this can have the helpful side effect of stimulating the baby to cry, which helps expand the lungs.
Name five common birth injuries [5]
- Caput Succedaneum
- Cephalohaematoma
- Facial Paralysis
- Erbs Palsy
- Fractured Clavicle
Describe the presentation of Erb’s palsy [5]
Damaged to the C5/C6 nerves leads to weakness of shoulder abduction and external rotation, arm flexion and finger extension. This leads to the affected arm having a “waiters tip” appearance:
* Internally rotated shoulder
* Extended elbow
* Flexed wrist facing backwards (pronated)
* Lack of movement in the affected arm
Describe the treatment of Erb’s palsy [1]
Function normally returns spontaneously within a few months. If function does not return then they may required neurosurgical input.
