Paeds - neonatology (0-finals) Flashcards
Why is compliance necessary? Explain the 2 ways surfactant helps.
Surfactant is produced by Type 2 alveolar cells between week 24-34.
It stops the alveoli from collapsing in on themselves by reducing the surface tension of the fluid of the lungs (stops the water molecules from pulling towards each other).
Therefore the surfactant keeps the alveoli inflated, maximising their surface area.
Increased compliance is when less force is required to expand the alveoli/ lungs during inspiration.
Surfactant also ensures the equal expansion of alveoli during inspiration.
When an alveoli expands, the surfactant molecules become more thinly spread which allows surface tension to increase again.
Therefore already expanded alveoli dont really expand more, allowing other alveoli to expand more.
Describe the cardio/ resp changes that happen during birth.
- thorax is squeezed as body passes through vagina, clearing fluid from lungs
- first breath is stimulated by birth/temp change/sound/physical touch
- adrenaline and cortisol are also released in response to labour stress, stimulating resp effort
- function of first breath is to expand collapsed alveoli for the first time
- This causes a drop in pulmonary vascular resistance
- Decrease in pulmonary vascular resistance causes a drop in RA pressure
- the LA pressure is greater than the RA pressure, causing a functional closure of the foramen ovale
- the foramen ovale then structurally closes = fossa ovalis
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Increased blood oxygenation causes a drop in circulating prostaglandins
- this causes closure of the ductus arteriosis = ligamentum arteriosus
- When umbilical cord is clamped and blood stops flowing through umbilical veins, ductus venosus stops functioning
- ductus venosus structurally closes a few days later = ligamentum venosum
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- ductus venosus structurally closes a few days later = ligamentum venosum
What are the risks and benefits of delayed umbilical cord clamping?
Benefits = delay clamping for at least 1 min in uncompromised babies
- placental transfusion! allows more foetal blood from placenta to enter the babys circulation
- improves Haemoglobin, iron stores, BP
- reduces risk of intraventricular haemorrhage and necrotising enterocolitis
Risk = babies that require neonatal resus should be clamped asap so resus team can work
- increase in neonatal jaundice (needs phototherapy)
What score would you use in neonatal resuscitation?
APGAR score
What are the 7 things you need to do for the baby immediately after birth?
- clamp the umbilical cord
- dry the baby
- keep the baby warm with a hat and blankets
- skin to skin
- vitamin K
- label the baby
- measure the weight and length
Why and how would you give vitamin K?
- babies are born with a vit K deficiency
- it will help prevent bleeding, particularly intracranial/ umbilical stump/ GI bleeding
- you generally give it as an IM injection in the thigh shortly after birth (helpful as also stimulates the baby to cry and expand its lungs)
- can also give it orally however takes longer to work (give at birth, 7 days, 6 weeks)
When would you initiate breast/ bottle feeding?
When would you have the first bath?
Feeding = as soon as baby is alert enough!
Bath = waituntil the baby is warm and stable. no issue waiting a few days!
What 3 examinations would you have to think about after leaving the delivery room?
- Newborn examination within 72 hours
- Blood spot test
- Newborn hearing test
What does the blood spot screening test for?
It is taken on day 5 with parents consent. (Day 8 latest)
- heel prick for 4 separate drops of blood
- takes 6-8 weeks to see results
Screens for 9 congenital conditions:
- Sickle cell disease
- Cystic Fibrosis
- Congenital hypothyroidism
- Phenylketonuria
- Medium-chain acyl-CoA dehydrogenase deficiency (MCADD)
- Maple syrup urine disease (MSUD)
- Isovaleric acidaemia (IVA)
- Glutaric aciduria type 1 (GA1)
- Homocystinuria (HCU)
You do the newborn examination within 72 hours of birth. When would you repeat it?
6-8 weeks by the GP
Newborn Examination - How would you measure the O2 sats?
- Measure pre-ductal saturations in the baby’s right hand
- RH gets blood from R Subclavian Artery, a branch of the brachiocephalic artery (which branches from aorta before ductus arteriosus)
- Measure post-ductal saturations from either foot
- feet receive blood from descending aorta (occurs after the ductus arteriosus)
- Normal saturations are 96% or above
- Ductus arteriosus stops functioning 1-3 days after birth
- Until then, it allows blood from deoxygenated R sided circulation to mix with oygenated L sided circulation after the lungs
- Certain congenital heart conditions are duct dependent (rely on the mixing of blood across the ductus arteriosus), and when the DA closes there can be a rapid deterioration
- therefore you can pick these up by measuring the difference in pre-ductal and post-ductal saturations
Newborn Examination - What would you look out for on examination of the head?
- size, shape, dysmorphology, caput succedaneum (swelling or oedema on scalp after delivery), cephalohaematoma (monitor for jaundice and anaemia), any facial injuries, etc
- occipital frontal circumference of head
- anterior and posterior fontanelles
- Sutures eg. overlapping sutures (typically resolve as baby grows)
- Ears = skin tags, low set, asymmetry
- Eyes = squints can be normal, epicanthic folds (Down’s), purulent discharge (infection)
- Red reflex using ophtalmoscope (check for symmetry) = absent with congenital cataracts and retinoblastoma
- Mouth = cleft lip or tongue tie
- little finger in mouth for suckling reflex, palpate all the way back to check for cleft palate
Newborn examination - What would you look for on the shoulders and arms?
- shoulder symmetry = check for clavicle fracture
- arm movements = check for erbs palsy
- brachial and radial pulses
- palmar creases = single palmar crease can be associated with Down’s
- Digits = number, straight, curved (clinodactyly)
- sats probe on right wrist for pre-ductal reading
Newborn examination - what would you look for in the abdomen?
- shape of abdomen = concave abdo can indicate diaphragmatic hernia with abdo contents in the chest
- umbilical stump = look for discharge, infection, periumbilical hernia
- Palpate for organomegaly, hernias, masses
Newborn Examination - what would you look for in the genitals on a newborn exam?
- observe for sex, ambiguity, abnormalities
- palpate testes and scrotum = check both are present and descended, check for hernias and hydroceles
- inspect penis = hypospadias, epispadias, urination
- inspect anus = patent?
- ask about meconium = has the baby opened their bowels?
Newborn Examination - What would you look for in a babys legs and back on the newborn examination?
Back
- inspect and palpate spine = curvature, spina bifida, pilonidal sinus
Legs
- observe legs and hips = equal movement, skin creases, tone and talipes
- Barlows and Ortolani manoeuvres = checks for clunking, clicking, dislocation of hips
- if clunking/clicking of hips = refer for hip US to rule out developmental dysplasia of hips
- Count toes
Newborn Examination - what are some reflexes that you would try to elicit in a newborn examination? (5)
- Moro reflex = arms and legs extend when baby is rapidly tipped backwards
- Suckling reflex = finger in the mouth will prompt them to suck
- Rooting reflex = tickling cheek will cause them to turn towards stimulus
- Grasp reflex = finger in their palm will cause them to grasp
- Stepping reflex = when held upright with their fee touching a surface, they will make a stepping motion
Newborn Examination - What are these skin findings that may be seen on a newborn?
haemangiomas
Newborn Examination - What are these skin findings that may be seen on a newborn?
erythema toxicum
What is talipes?
- clubfoot
- where the ankles are in supinated position (rolled inwards)
- positional talipes = muscles are tight around the ankle
- bones unaffected so foot can still be moved into normal position via physiotherapist and simple exercises
- structural taplies = involves bones of foot and ankle
- requires referral to orthopaedic surgeon
What condition are port wine stains associated with?
Sturge-Weber syndrome
can have visual impairment, learning difficulties, headaches, epilepsy, glaucoma
Where would you document the newborn examination?
- on the Newborn and Infant Physical Examination (NIPE) computer system
- baby’s Red Book
Birth Injuries - What is caput succedaneum?
- fluid (oedema) collecting on the scalp outside the periosteum
- due to pressure to a specific area of the scalp during traumatic/ prolonged/ instrumental delivery
- fluid is outside of periosteum so can cross suture lines
- usually resolves within a few days
Birth injuries - What is cephalohaematoma?
- Also described as “Traumatic Subperiosteal Haematoma”
- due to damage to the blood vessels during a traumatic/ prolonged/ instrumental delivery
- collection of blood between the skull and the periosteum
- As it is below the periosteum, the lump does not cross the suture lines of the skull (unlike caput succedaneum)
- the blood also can cause discolouration of the skin in the affected area (unlike caput succedaneum which will have no or only mild discolouration)
- Monitor as there is a risk of jaundice or anaemia (blood that builds up in the haematoma can break down and release bilirubin)
Birth Injuries - what method of delivery would increase the risk of facial paralysis?
Forceps delivery is associated with facial nerve injury.
Function normally returns spontaneously within a few months, otherwise requires neurosurgical input
What is Erbs palsy and how would it happen in birth?
- injury of C5/C6 nerves in the brachial plexus!
- results in weakness of shoulder abduction and external rotation, arm flexion and finger extension = “Waiter’s Tip”
- internally rotated shoulder
- extended elbow
- flexed wrist facing backwards (pronated)
- lack of movement in affected arm
- Associated with shoulder dystocia, traumatic/ instrumental delivery, large birth weight
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Birth Injuries - How would you diagnose a clavicle fracture and how would it happen in birth?
- confirmed with US or Xray
- presents on newborn exam with:
- noticeable lack of movement in affected arm
- asymmetry of shoulders (affected shoulder lower than normal shoulder)
- pain and distress on movement of the arm
- associated with shoulder dystocia, traumatic/instrumental delivery, large birth weight
- Management = immobilisation of arm (conservative)
- Risk = injury to brachial plexus and nerve palsy
What are some common organisms to think about when thinking about neonatal sepsis?
- Group B Streptococcus (GBS) = especially if there is maternal vaginal GBS colonisation during pregnancy
- Escherichia coli
- Listeria
- Klebsiella
- Staphylococcus aureus
What are some risk factors for neonatal sepsis?
- vaginal GBS colonisation
- GBS sepsis in previous baby
- maternal sepsis, chorioamnionitis or fever >38C
- Prematurity <37 weeks
- early (premature) rupture of membranes
- prolonged rupture of membranes (PROM)
What are some features and red flags of neonatal sepsis?
Clinical features:
- fever
- redued tone and activity
- poor feeding
- resp distress or apnoea
- vomiting
- tachycardia or bradycardia
- hypoxia
- jaundice within 24 hours
- seizures
- hypoglycaemia
Red flags
- confirmed or suspected sepsis in mother
- signs of shock
- seizures
- term baby needing mechanical ventilation
- resp distress starting more than 4 hours after birth
- presumed sepsis in another baby in a multiple pregnancy
How would you manage presumed sepsis?
Initial…
- If there is one risk factor OR clinical feature, monitor obs and clinical condition for at least 12 hours
- Blood cultures before antibiotics
- Check FBC and CRP
- Lumbar Puncture if infection is strongly suspected or there are features of meningitis eg. seizures
- If there are 2 or more risk factors OR clinical features, start antibiotics
- also start antibiotics if there is 1 red flag
- give antibiotics within 1 hour of deciding to start them
- 1st line = benzylpenicillin and gentamycin
- (cefotaxime or a 3rd gen cephalosporin is an alternative in lower risk babies)
Later…
- Blood cultures should be back in 36 hours
- Check CRP again in 24 hours
- Stop antibiotics if baby is clinical well, blood cultures are -ve 36 hours later & both CRP results are <10
- Consider an LP if any CRP is >10
- Check CRP again in 5 days if still on treatment
- Stop antibiotics if CRP is normal in 5 days, baby is clinically well, and LP and blood cultures are -ve
What is Hypoxic-Ischaemic encephalopathy (HIE) and when would you suspect it?
When there is prolonged or severe hypoxia during birth which leads to ischaemic brain damage.
Permanent damage can result in cerebral palsy, severe cases can result in death.
You would suspect it in any neonates who have experienced…
- events that could lead to hypoxia in the perinatal or intrapartum period
- acidosis on the umbilical abg
- poor Apgar scores
- features of HIE
- evidence of multi organ failure
What are some causes of HIE?
Anything that can lead to asphyxia to the brain can cause HIE:
- maternal shock
- intrapartum haemorrhage
- prolapsed cord which can cause compression of the cord during birth
- nuchal cord (cord wrapped around babys neck)
What is the staging for HIE and name some mild features
Sarnat Staging
Mild features of HIE:
- poor feeding
- generally irritable and hyper-alert
- resolves within 24 hours
- normal prognosis
Name some moderate features of HIE
- poor feeding, lethargic, hypotonic, seizures
- Can take weeks to resolve
- up to 40% develop cerebral palsy
Name some features of severe HIE
- reduced consciousness, apnoeas, flaccid and reduced or absent reflexes
- up to 50% mortality
- up to 90% develop cerebral palsy
How would you manage hypoxic-ischaemic encephalopathy?
- supportive care eg. neonatal resus, ventilation, nutrition, acid base balance, treatment of seizures, circulatory support
- Therapeutic Hypothermia
- baby is transferred to neonatal ICU and cooled using cooling blankets and a cooling hat
- temp targeted between 33-34C measured using a rectal probe
- Continue cooling for 72 hours, then gradually warm baby back up to normal temp over 6 hours
Goal of therapeutic hypothermia is to reduce inflammation and neurone loss after acute hypoxic injury.
Reduces risk of cerebral palsy, developmental delay, LD, blindness and death.
How would you investigate meconium aspiration syndrome?
- chest xray will show:
- increased lung volumes
- asymmetrical patchy pulmonary opacities
- pleural effusions
- pneumothorax or pneumomediastinum
- multifocal consolidation due to chemical pneumonitis
- FBC, CRP, Blood cultures
- ABG
- Dual pulse oximetry (right upper limb and either lower limb for pre and post ductal)
- Echocardiography to exclude congenital heart abnormalities causing the pulmonary htn
- cranial US to assess any hypoxic damage to the brain
Newborn Examination - What are these skin findings that may be seen on a newborn?
Port wine stain
Newborn Examination - What are these skin findings that may be seen on a newborn?
Mongolian Blue Spot
Newborn Examination - What are these skin findings that may be seen on a newborn?
Cradle Cap
Newborn Examination - What are these skin findings that may be seen on a newborn?
Desquamation
Newborn Examination - What are these skin findings that may be seen on a newborn?
Milia
Newborn Examination - What are these skin findings that may be seen on a newborn?
Naevus simplex (stork bite)
Newborn Examination - What are these skin findings that may be seen on a newborn?
Transient Pustular Melanosis
What are 3 neural tube defects?
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Spina bifida occulta
- absent posterior vertebral arch hasnt fused
- no neuro deficit
- presents with hairy patch on skin, growth and cord tethering
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Meningocoele
- herniation of pia and arachnoid filled with CSF
- no neuro deficit
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Myelomeningocoele
- usually open with exposed meninges and leaking CSF
- neuro deficits eg. motor/sensory loss in LL, neuropathic bladder and bowel
- typically gets scoliosis and hydrocephalus due to Arnold-Chiari malformation (herniation of cerebellar tonsils thorugh foramen magnum)
- surgery prevents infection but cannot restore function
