Paeds- Neonates Flashcards
Important problems with neonatal resuscitation
Hypoxia occurs during normal birth, babies have large surface area to volume ratio so loose heat, babies are born wet so loose heat, babies can aspirate Meconium in birth
First stage of neonatal resuscitation
Dry and warm the baby- towel, heat lamp, bag if less than 28 weeks
What are APGAR scores and when are they done
Appearance, Pulse, Grimmace, Activity, Respiration
Performed at 1, 5 and 10 minutes post birth
Range from 0-10
If neonate is not breathing/gasping despite stimulation what is the first stage of resuscitation
Inflation breaths- 5 breaths
Can be repeated
What can be given after inflation breaths if no progress?
30 seconds of ventilation breaths
When should chest compressions be given in neonatal resuscitation
If heart rate is less than 60 despite inflation and ventilation breaths
Rate of chest compressions in neonates
3:1 with inflation breaths
Explain delayed cord clamping
If neonate is uncompromised cord clamping should be delayed by at least one minutes to allow all blood to enter baby
What is Meconium aspiration
Respiratory distress which is caused by the aspiration of Meconium stained amniotic fluid either antenatally or during birth.
Pathophysiology of Meconium aspiration
Meconium usually passes after birth however if in utero peristalsis it can occur earlier
This is usually due to foetal hypoxic stress or vagal stimulation due to cord compression
This leads to Meconium stained amniotic fluid
The neonate can aspirate the Meconium
Consequences of Meconium aspiration
Partial or total airway obstruction (due to thick sticky consistency of Meconium, can cause partial collapse)
Foetal hypoxia
Pulmonary inflammation- meconium contains pro-inflammatory cytokines
Infection
Surfactant inactivation - inflammatory reaction can deactivate surfactant
Persistent pulmonary hypertension of the newborn
Presentation of Meconium aspiration
Respiratory distress signs:
- Tachypnoea,
- tachycardia
- cyanosis
- grunting
- nasal flaring
- recessions
Differentials of meconium aspiration
Transient Tachypnoea of the newborn
Surfactant deficiency
Persistent pulmonary hypertension
Cyanotic congenital heart disease
Diagnosis of meconium aspiration
X ray- increased lung volumes, patchy pulmonary infiltrates, may have effusion or pneumothorax
May blood culture to rule out infection
Treatment of Meconium aspiration
Depends on the severity of resp distress
- ventilation and oxygen therapy
- antibiotics may be given if concern for infection
- surfactant if severe
- inhaled nitric oxide for hypertension
RF for meconium aspiration
Increased gestational age- >42 weeks, foetal distress, intrapartum hypoxia, chorioamnionititsm maternal hypertension, smoking, diabetes
What needs to be considered if bowel sounds can be heard on a respiratory examination of a neonate
diaphragmatic hernia
how does a diaphragmatic hernia present in a neonate
respiratory distress shortly after birth due to lung hypoplasia
What management can be done to reduce risk of HIE in neonates
therapeutic cooling
How does prader willi present in neonates?
neonatal hypotonia
What is Epstein’s pearl?
a white lesion found on the posterior hard palate- sometiems mistaken for neonatal teeth
features of fetal alcohol syndrome
flat philtrum, sunken nasal brdige, small eye openings, small body, low set ears, thin upper lip
x ray findings of meconium aspiration syndrome
patchy infiltrations and atelectasis
What investigation is needed for all babies who were breech at or after 36 weeks gestation, regardless of neonatal examination
hip ultrasound at 6 weeks
what complication may occur after ventouse delivery
cephalohaematoma
How does neonatal hypoglycaemia present
jitteriness
irritable
tachypnoeic
poor feeding
drowsy
hypotonia
apnoea
first line treatment of an ASYMPTOMATIC baby with hypoglycaemai
encourage normal feeding and monitor
first line treatment of a symptomatic neonate with hypoglycaemia
admit to neonatal unit
give IV infusion of 10% dextrose
If a neonate has spO2 of 85% 5 mins after birth what should be done
remeasure in 5 mins- suboptimal levels are normal in initial 10 mins
What two prognostic markers can be used to determine the prognosis of a congenital diaphragmatic hernia
liver position and lung to head ratio
When do the lungs start producing surfactant
after 30 weeks gestation
Pathophysiology of respiratory distress syndrome
inadequate surfactant causes alveoli to collapse on expiration which increases the energy needed for breathing.
Inadequate gas exchange leads to subsequent hypoxia and carbon dioxide retention
Presentation of respiratory distress syndrome
respiratory distress immediately or within minutes of birth
tachypnoea
nasal flaring
expiratory grunting
subcostal and intercostal recessions
cyanosis
diminished breath sounds
How does respiratory distress syndrome present on X ray/lung USS
ground glass appearance
what is oesophageal atresia?
a condition where a short section of the top of the oesophagus has not formed properly meaning it is not connected to the stomach.
what is a tracheo-oesophageal fistula and what condition does it usually accompany?
it is a connection between the oesophagus and the trachea
can occur alongside oesophageal atresia
What obstetric condition may present with oesophageal atresia
polyhydramnios
pathophysiology of oesophageal atresia
the oesophagus and the trachea start as a single tube (arising from the common fore gut) in development and then divide into two distinct structures.
Separation usually starts during the 4th week of gestation- failure of this can occur can lead to atresias and fistula formation
How does oesophageal atresia present?
baby will not be able to feed - will cough and splutter during feeding
frothy bubble may come out of mouth
baby may choke
How is oesophageal atresia diagnosed?
may be identified on USS during pregnancy
May present as failure to pass an NG tube down the babies nose and. into the stomach.
Xrays and endoscopy may be used
How are oesophageal atresias treated?
immediate surgical intervention
What is cleft lip
a congenital condition where there is a split or open section of the upper lip
what is a cleft palate
a defect exists in the hard or soft palate of the roof of the mouth- leads to an opening between the mouth and the nasal passage
what maternal drug may increase the risk of cleft lip and palate
epileptic use
When are cleft lip and palate surgeries done
cleft lip- 3 months
cleft palate- 6-12 months
What are the TORCH infections
Toxoplasma gondii
Other agents- Treponema pallidum (syphilis), VZV, parvovirus, HIV
Rubella
Cytomegalovirus
Herpes simplex virus
Complications of toxoplasmosis gondii infection to the foetus
Chorioretinitis
Hydrocephalus
Rash
Intracranial calcifications
Complications of Rubella infection in the foetus
congenital rubella syndrome- cataracts, rash, heart defects, deafness
How does cytomegalovirus present in foetus
rashes, deafness, inflammation of the eye, seizures, microcephaly
How does congenital syphilis present?
death, craniofacial malformations, rash, deafness
how does parvovirus B19 present in neonates
anaemia of the newborn, fetal hydrops
How does meconium aspiration present?
signs of respiratory distress in the newborn- tachypnoea, tachycardia, cyanosis, grunting, nasal flaring, recessions, hypotension, barrel shaped chest
born with green stained amniotic fluid
May appear normal straight after birth and then develop respiratory distress hours after
Pathophysiology of meconium aspiration
in utero massage of meconium leading to meconium-stained amniotic fluid
This usually occurs due to foetal hypoxic stress (e.g. placental insufficiency) or vagal stimulation caused by cord compression
The foetus aspirates the MSAF either antenatally or during birth
Leads to airway obstruction, foetal hypoxia, pulmonary inflammation, infection, surfactant inactivation and persistent pulmonary hypertension.
How does meconium aspiration present on x ray
increased lung vomules
asymmetrica patchy infiltrations
pleural effusions
pneumothorax
How is meconium aspiration treated
depends on the severity of respiratory distress:
- suctioning the infant after birth
- warm infant
- oxygen therapy: nasal cannula, CPAP, intubation
-antibiotics if suspicion of infection
- Surfactant
- inhaled nitric oxide - occurs if the infant requires mechanical ventilation and surfactant
RF for meconium aspiration
- increased gestational age after 42 weeks
- foetal distress
- placental insufficiency
- chorioamnionitis +/- prolonged pre-rupture
- oligohydramnios
- in utero growth restriction
- maternal hypertension, diabetes, pre-eclampsia, or eclampsia
complications of meconium aspiration
long term neurological sequale- cerebral palsy
respiratory damage from prolonged ventilator use
why may neonates get physiological jaundice
- there is marked release of haemoglobin from the breakdown of RBC as there is high haemoglobin at brith
- the RBC lifespan in neonates is 70 days (less than 120 in adults)
- hepatic bilirubin metabolism is less effective in the first days of life
what can cause early jaundice (within the first 24 hours of birth)
haemolytic disorders (rhesus disease, ABO incompatibility, G6PD deficiency, hereditary spherocytosis)
congenital infection (TORCH)
what can cause jaundice in a newborn between 24 hours-2 weeks
physiological jaundice
breastmilk jaundice
infection (e.g. UTI)
haemolysis
bruising
What is prolonged jaundice
jaundice lasting longer than 2 weeks (or 3 weeks if preterm)
What can cause prolonged jaundice in infants?
give examples on conjugated and un conjugated
unconjugated- physiological, breast milk, infection, congenital hypothyroidism, pyloric stenosis
conjugated- biliary atresia, neonatal hepatitis
what is a serious complications of neonatal jaundice
kernicterus
what is kernicterus
encephalopathy that results from deposition of the unconjugated bilirubin in the basal ganglia and brainstem nuclei
how does kernicterus present?
lethargy, poor feeding, irritability, increased muscle tone
opisthotonos (baby lays with back arched)
seizure and coma
what is a long term complication of kernicterus
cerebral palsy - choreoathetoid cerebral palsy
Investigations that might be used in neonatal jaundice
direct coombs test
blood film
infection investigations- cultures, CSF, urine
transcutaneous bilirubinometer and blood bilirubin
How does conjugated bilirubinaemia presetn
pale stools and dark urine
How is neonatal jaundice treated
- treat underlying cause
- maintain good hydration (poor intake will exacerbate)
- phototherapy (with blue-green band visible light)
- exchange transfusion
how soon after commencing phototherapy should bilirubin levels be assessed
4-6 hours
are neonatal inflation breathes given with air or 100% oxygen
air
What is raised in physiological jaundice
Unconjugated bilirubin
What is seen on x ray of a baby with transient tachypnoea of the neonate
Hyperinflation and fluid in the horizontal fissure
What causes transient tachynpnoea if the newborn
Delayed resorption of fluid in the lungs
What makes up the TORCH infections
Toxoplasmosis
Other- syphillis, VZV, parvovirus
Rubella
Cytomegalovirus
Herpes simple virus
How is toxoplasmosis transmitted (2)
exposure to undercooked meat
cat faeces
How does congential toxoplasmosis present? (5)
intracranial calcifications
hydrocephalus
chorioretinitis
retinopathy
cataracts
How does congential syphilis present? (6)
blunted incisor teeth (Hutchinson teeth)
Rhagades (linear scars at the angles of the mouth)
Keratitis
Saber shins
saddle nose
deafness
How does congential varicella zoster present? (5)
skin scarring
eye defetcs (microphthalmia)
limb hypoplasia
microcephaly
learning difficulties
at what gestation is parvovirus B19 likely to effect the foetus
if exposed before 20 weeks gestation
How can parvovirus effect the foetus - explain the pathophysiology and how it presents in fetus
Parvovirus can cross the placenta and suppress foetal erythropoiesis (as infects erythroid progenitor cells)
- this can cause fetal anaemia and subsequent heart failure
- presents as hydrops fetalis- ascites, pleural effusions, pericardial effusions
How is parvovirus infection of foetus treated
repeat intrauterine blood transfusions
when are foeteses at highest risk for congenital rubella
8-10 weeks
How does congenital rubella syndrome present? (9)
sensorineural deafness
congenital cataracts
congenital heart defects
growth retardation
hepatosplenomegaly
purpuric skin lesions
salt and pepper chorioretinitis
microphthalmia
cerebral palsy
How does congenital cytomegalovirus present? (6)
growth retardation
pinpoint petechial blueberry muffin rash
microcephaly
sensorineural hearing loss
encephalitis
hepatosplenomegaly
How can herpes simplex virus effect a newborn if transmitted in labour
blisters and meningioencephalitis
if a mother has primary herpes infection after 28 weeks gestation what is the management
immedicate course of aciclovir then continuous prophylactic aciclovir until delivery
caesarean recommended
if a mother has primary herpes infection before 28 weeks/ pre-existing HSV, what is the treatment?
the should be given prophylactic aciclovir from 36 weeks
if no infection at time of birth then vaginal delivery can be done
what is biliary atresia?
a congenital condition where a section of the bile duct is either narrowed or absent
Path of biliary atresia
there is a narrowed/ absent section of the bile duct which leads to cholestasis
The baby cannot excrete conjugated bilirubin so it builds up and they become jaundiced
How does biliary atresia present ?
-significant prolonged jaundice
-dark urine and pale stools
-failure to thrive (poor absorption of long chain fats)
-hepatomegaly
-ascites
-bruising (coagulopathy due to vitamin K deficiency)
Differentials of biliary atresia
hepatic viral infections
alagille syndrome
alpha-1- antitrypsin deficiency
downs syndrome
cystic fibrosis
diagnosis of biliary atresia
raised conjugated bilirubin
LFTs- shows disproportionately high GGT
abdominal USS
percutaneous liver biopsy with intraoperative cholangioscopy
How is biliary atresia treated ?
hepatoportoenterostomy - surgical excision of the obliterated extrahepatic ducts
2nd line- liver transplant
Complications of biliary atresia
growth failure
cholangitis
portal hypertension
GI bleed
vitamin deficiency
what antenatal condition is duodenal atresia associated with?
polyhydramnios
How does duodenal atresia present?
distended abdomen and vomiting within hours of birth
vomiting can be bilious or non-bilious depending on the site of obstruction
How is duodenal atresia diagnosed?
abdominal x-ray: double bubble sign
How is duodenal atresia treated?
fluids and surgery (duodenoduodenostomy)
Where is the abnormality in most congenital diaphragmatic hernias?
in the posterolateral segment (Bochdalek hernia)
How do congenital diaphragmatic hernias present? (5)
-severe respiratory distress immediately after birth
-heart sounds on the right side of the chest
-absence of left sided breath sounds
-scaphoid abdomen
-bowel sounds on the left side of the chest
what is a gastroschisis?
a type of abdominal wall defect that occurs when the childs abdomen does not develop fully while in the womb - this means the intestines develop outside the abdomen
How is gastrschisis managed?
the baby will be immediately wrapped in clingfilm then undergo immediate abdominal surgery wehre the bowel is pushed into the abdomen and closed
may need TPN for a period of time while intestines arent working
what is exomphalos?
where the abdominal contents protrude through the anterior abdominal wall but are covered with an amniotic sac formed from amniotic membrane and peritoneum
How is exomphalos managed?
caesarean section should be done to avoid rupture of the sac
Staged repair after birth as oppose to gastroschisis
Describe how birth might differ in gastroschisis and exomphalos?
gastroschisis may have vaginal delivery
exomphalos needs caesarean to prevent rupture of sac
what are some associated conditions with exomphalos
Beckwith-Wiedemann syndrome
Downs syndrome
cardiac and kidney deformities
How does neonatal listeriosis present?
bronchopneumonia
meningitis
conjunctivitis
skin rash
How is neonatal listeriosis treated?
IV ampicillin or IV aminoglycoside for at least 5 days
How is neonatal listeriosis prevented?
by pregnant women not eating mould-ripened soft cheese, pate, uncooked/undercooked ready meals and not drinking unpasteurised milk
What is the time frame of neonatal sepsis
in the first 28 days of life
What is early onset neonatal sepsis
sepsis within the first 72 hours of birth
what is late onset neonatal sepsis
sepsis between 3 and 28 days of life
what are some RF for neonatal sepsis
sibling with GBS infection
mother with GBS infection at time of birth
mother with bacteruria at time of birth
intrapartum temperature >38
membrane rupture >18 hours
mother with current infection at time of labour
premature infants <37 weeks
low birth weight (<2.5kg)
evidence of chorioamnionitis
what are the most common causes of early onset neonatal sepsis?
organisms from the mothers genital tract- mainly Group B streo, other could be E.coli
What are the most common causes of late onset neonatal sepsis?
organisms that have been transmitted from the environment to the neonate (commonly from parents or healthcare workers)
causes include:
- staph epidermidis
- pseudomonas aeruginosa
- klebsiella
-enterobacter
How does neonatal sepsis present?
resp distress
tachycardia
apnoea
lethargy
jaundice
seizures
hypoxia - cyanosis
poor feeding
abdominal distention
vomiting
temperature (preterm infants might be hypothermic)
How is neonatal sepsis diagnosed?
blood cultures
FBC
CRP
Blood gases
urine microscopy, cuture and sensitivity
LP
what one blood gas is a bad sign in neonatal sepsis
metabolic acidosis
What antibiotics are used to treat neonatal sepsis
IV benzylpenicillin and gentamycin
What blood measurement is used to guide treatment of neonatal sepsis
CRP
When can antibiotics for neonatal sepsis be stopped?
If negative cultures at presentation and CRP<10 they can be stopped at 48 hours
If culture confirmed sepsis then they need to be continued for at least 7 days
Which women need intrapartum antibiotic prophylaxis?
preterm labour
group B strep, bacteruria or infection in current pregnancy
group B strep, bacteruria or infection in previous pregnancy if no negative swabs done at 35-37 weeks (or 3-5 weeks before delivery)
baby with previous invasive GBS disease
possible chorioamnionitis
how soon before delivery should intrapartum antibiotic prophylaxis be started?
at least 2 hours prior to delivery
What condition is characterised by the double bubble sign on x ray?
bowel atresia
How does duodenal atresia present?
antenatal polyhydramnios
distended abdomen
vomiting- bilious or non-bilious depending on site of atresia
onset usually within hours of birth
how is duodenal atresia treated?
fluid resuscitation and surgical repair - dudenoduodenostomy
causes of neonatal hypoglycaemia (7)
preterm birth- less than 37 weeks
maternal diabetes mellitus
intrauterine growth restriction
hypothermia
neonatal sepsis
inborn errors of metabilism
beckwith weidemann syndrome
foetal alcohol syndrome presentation
specific facial abnormalities such as short palpebral fissures, smooth philtrum and thin upper lip
