Paeds neonates Flashcards
What is the APGAR score used for?
To indicate progress over the first 5 minutes after birth
What is the APGAR score out of?
10
What are the components of the APGAR score?
- Appearance (skin colour)
- Pulse
- Grimmace (response to stimulation)
- Activity (muscle tone)
- Respiration
For each aspects of the APGAR score, what points can you score?
0, 1 or 2
What merits point in the Pulse section of the APGAR score?
- Absent - 0
- <100 - 1
- > 100 - 2
What does delayed cord clamping reduce the risk of? What does it increase the risk of?
- Reduces risk of intraventricular haemorrhage and necrotising enterocolitis
- Increases risk of neonatal jaundice
What is the first stage of neonatal resuscitation? What is they are under 28 weeks?
- Dry the baby
- Babies under 28 weeks are placed in a plastic bag while still wet and managed under a heat lamp
What is the most common cause of neonatal sepsis?
Group B streptococcus
When should antibiotics for neonatal sepsis be commenced?
- If there are 2 or more risk factors or clinical features of sepsis
- If there is a single red flag for sepsis
What are first line antibiotics for neonatal sepsis?
Benzylpenicillin + gentamycin
When should CRP be checked in babies with neonatal sepsis?
- Immediately
- At 24 hrs
- At 36 hrs
- At 5 days IF they are still on treatment
Give 4 causes of hypoxic ischaemia encephalopathy
- Maternal shock
- Intrapartum haemorrhage
- Prolapsed cord
- Nuchal cord
What % of babies with severe hypoxic ischaemic encephalopathy develop cerebral palsy
90%
Other than supportive management what treatment can help protect the brain from hypoxic injury?
Therapeutic hypothermia
What is the goal of therapeutic hypothermia?
To reduce inflammation and neurone loss after acute hypoxic injury
What temp are neonates cooled to for therapeutic hypothermia? For how long?
- 33-34 degrees
- 72 hours
When does normal neonatal jaundice appear and resolve by?
- Day 2-7
- Day 10
When is neonatal jaundice considered pathological?
Jaundice in the first 24 hrs of life
How can the causes of neonatal jaundice be divided?
- Increased production of bilirubin
- Decreased clearance of bilirubin
What is kernicterus?
Brain damage due to high bilirubin levels
What is the reason for breast milk jaundice?
Components of breast mild inhibit the ability of the liver to process the bilirubin
What causes haemolytic disease of the newborn?
Incompatibility between the rhesus antigens on the surface of the red blood cells of the mother and foetus
What is classed as prolonged jaundice in full term babies?
Jaundice >14 days
What is classed as prolonged jaundice in premature babies?
Jaundice >21 days
Give 3 causes of prolonged jaundice
- Biliary atresia
- Hypothyroidism
- G6PD deficiency
What blood test would detect haemolysis?
Direct Coombs Test
In jaundiced neonates, what are total bilirubin levels plotted and monitored on?
Treatment threshold charts
What happens in kernicterus?
Bilirubin crosses the blood-brain barrier
How does kernicterus present?
- Less responsive
- Floppy baby
- Poor feeding
Who does necrotising enterocolitis affect?
Premature neonates
What happens in necrotising enterocolitis?
The bowel becomes necrotic
True/false: NEC is less common in babies fed by breast milk
True
What is pneumatosis intestinalis? What’s it a sign of?
- Gas in the bowel wall
- NEC
What is pneumoperitoneum? What does it indicate?
- Gas in the peritoneal cavity
- Perforation
What is the management of NEC?
- Nil by mouth
- IV fluids
- TPN
- Antibiotics
- Surgery to remove the dead bowel tissue
Who does respiratory distress syndrome affect?
Premature neonates born before the lungs start producing adequate surfactant
What would chest XR show in respiratory distress syndrome?
‘Ground-glass’ appearance
What is the management of respiratory distress syndrome?
- Intubation and ventilation
- Endotracheal surfactant
- Continuous positive airway pressure (CPAP)
- Supplementary oxygen
What do you want to maintain oxygen sats between in preterm neonates?
91-95%
What is an apnoea?
A period where breathing spontaneously stops for more than 20 seconds, or shorter periods with oxygen desaturation or bradycardia
What causes apnoeas?
Immaturity of the autonomic nervous system that controls respiration and heart rate
What can be used to prevent apnoea and bradycardia in babies with recurrent apnoeas?
IV caffeine
What can be given to neonates with moderate/severe symptoms of:
1) opiate withdrawal
2) non-opiate withdrawal
- Oral morphine sulphate
- Oral phenobarbitone
What is prematurity defined as?
Birth before 37 weeks gestation
What options are there for improving outcomes when preterm labour is suspected or confirmed?
- Tocolysis with nifedipine (suppresses labour)
- Maternal corticosteroids (offered before 35 wks)
- IV magnesium sulphate (offered before 34 wks to protect brain)
- Delayed cord clamping (increase Hb and circulating blood volume in baby)
Caput succedaneum:
1) What is is?
2) What causes it?
3) What is the periosteum?
- A collection of fluid on the scalp, outside the periosteum
- Pressure to a specific area of the scalp e.g. during instrumental delivery
- Connective tissues that lines the outside of the skull and does not cross suture lines
Does fluid cross suture lines in caput succedaneum or cephalohaematoma?
Caput succedaneum as fluid is not limited by periosteum
Cephalohaematoma:
1) What is it?
2) What is it caused by?
3) What is there a risk of?
- A collection of blood between the skull and periosteum
- Damage to blood vessels during a traumatic. prolonged or instrumental birth
- Anaemia and jaundice due to blood that collects and breaks down (releasing bilirubin)
Facial paralysis:
1) What is biggest rf?
2) Prognosis?
- Forceps delivery
- Function normally returns spontaneously within a few months
Erbs palsy:
1) What is it injury to?
2) What is it caused by?
2) How does it present?
3) Prognosis?
- C5/C6 nerves in the brachial plexus
- Shoulder dystocia, traumatic/instrumental delivery, large birth weight
- Weakness in shoulder abduction, external rotation, arm flexion, finger extension (waiters tip appearance)
- Spontaneously revolves within a few months
What are 4 features of fetal alcohol syndrome?
- Microcephaly
- Thin upper lip
- Smooth flat philtrum
- Short palpebral fissure
Can pregnant women receive the MMR vaccine?
No - as it is a live vaccine
How can pregnant women be tested for chicken pox immunity?
Check IgG levels for VZV
What surgical procedure is used to treat Hirschsprung’s disease? What is done?
- Swenson Procedure
- Section of affected bowel is removed and remaining bowel is anastomosed together
What is the name of the surgical procedure done in symptomatic Meckel’s diverticulum?
Wedge excision
What is used to diagnose haemolytic anaemia?
Direct Coombs Test
What is hydrops fetalis?
Abnormal accumulation of serous fluid in 2+ fetal cavities (ascites, pleural effusions, pericardial effusions) and generalised skin oedema.
What are the 2 types of hydrops fetalis? Which is more common?
- Immune
- Non-immune (more common)
What causes immune hydrops fetalis?
Rh incompatibility
What causes non-immune hydrops fetalis?
Anything that interferes with how the baby manages fluid
- Severe anemia
- Infections present before birth
- Heart or lung defects
- Chromosomal abnormalities and birth defects
- Liver disease
What do you see on XR in NEC?
- Dialted bowel loops
- Bowel wall oedema
- Pneumonitis intestinalis
What blood gas finding is associated with severe NEC?
Metabolic acidosis
What are 3 causes of cyanotic heart disease?
- TOF
- Transposition of the great arteries
- Tricuspid atresia
What 3 ways can cryptorchidism present?
- Retractable
- Palpable
- Impalpable
What is absent in Hirschsprung’s disease? Where are they absent?
- Nerves cells of the myenteric plexus (importantly parasympathetic ganglion cells)
- In the distal bowel and rectum
How does Hirschsprung’s disease present?
- Delay in passing meconium
- Chronic constipation from birth
- Abdo distension
- Vomiting
- FTT
Hirschsprung-Associates Enterocolitis:
1) What is it?
2) When does it typically present?
3) What does it present with?
4) What can it lead to?
1) Inflammation and obstruction of the intestine in Hirschsprung’s disease
2) 2-4 wks from birth
3) Fever, abdo distension, diarrhoea, features of sepsis
4) Toxic megacolon and perforation
Hirschsprung’s disease investigations:
1) What can be helpful in diagnosis?
2) What confirms the diagnosis? What does it show?
1) Abdo XR
2) Rectal biopsy - an absence of ganglionic cell
What is the definitive management of Hirschsprung’s disease
Surgical removal of the ganglionic section of bowel
Give five reasons for transient jaundice after birth
- Polycythaemia (high conc of RBC)
- Shorter life span of HbF (80 days vs 120 days)
- Immaturation of UDPGT (what converts uncojugated to conjugated bilirubin)
- Low intrahepatic binding proteins
- High beta-glucuronidase in small bowel brush boarder (reverses conjugation)
What are 3 common causes of jaundice in the first 24 hrs of life?
- Haemolysis
- Sepsis
- Bruising
What are 3 causes of prolonged jaundice?
- Hepatic enzyme defects (Gilbert syndrome)
- Inborn errors of metabolism
- Hypothyroidism
Why do you get jaundice in Gilbert syndrome?
Reduced UDPGT activity. UDPGT is the enzyme that converts unconjugated bilirubin into conjugated bilirubin
How does non IgE mediated cows milk protein allergy present? What can it be triggered by?
- 72hrs from ingestion
- Frequent loose stool with blood and mucus
- Follows viral gastroenteritis
What are 3 management options for neonatal jaundice?
- Phototherapy - converts bilirubin into soluble products that can be excreted
- Exchange transfusion - warmed blood given via umbilical vein (twice babies volume is given)
- IVIg (if haemolytic disease)
What medication can cause NEC?
NSAIDS
What is another name for tongue tie?
Ankyloglossia
What is the reason for tongue tie? What is the management?
- A short and tight lingual frenulum
- Frenotomy
What is failure to thrive?
Less than expected growth during the first 3 years of life (when growth is recorded on growth charts)
What are the 4 drivers of failure to thrive?
- Inadequate intake - anything that impacts feeding
- Inadequate retention - vomiting/GORD
- Malabsorption - coeliac
- Increased requirements - malignancy, congenital HF, thyrotoxicosis
