Paeds neonatology Flashcards
Physiological jaundice resolves completely by… days
10 days
Physiological jaundice cause and presentation
Causes of neonatal jaundice
Babies with jaundice within 24 hours of birth need treatment for
sepsis if they have any other clinical features or risk factors
In premature babies, the process of physiological jaundice is exaggerated due to
the immature liver
Jaundice in premature neonates: neonates have increased risk of which complication
kernicterus
Postnatally, Babies that are…are more likely to have neonatal jaundice
breastfed
Why are breastfed babies more likely to have neonatal jaundice
- Components of breast milk inhibit the ability of the liver to process the bilirubin.
- Breastfed babies are more likely to become dehydrated if not feeding adequately.
- Inadequate breastfeeding may lead to slow passage of stools, increasing absorption of bilirubin in the intestines.
What advice is given to mothers about breast milk jaundice
Breastfeeding should still be encouraged, as the benefits of breastfeeding outweigh the risks of breast milk jaundice.
Mothers may need extra support and advice to ensure adequate breastfeeding.
Haemolytic disease of the new born causes which two key processes?
haemolysis (red blood cells breaking down) –> anemia
and jaundice (high bilurubin levels) in the neonate
Cause of haemolytic disease of new-born
incompatibility between the rhesus antigens on the surface of the red blood cells of the mother and fetus.
(rhesus negative mother and rhesus positive baby in 2nd pregnancy)
Jaundice is “prolonged” when it lasts longer than would be expected in physiological jaundice. This is:
o More than…days in full term babies
o More than… days in premature babies
More than 14 days in full term babies
More than 21 days in premature babies
conditions that will cause jaundice to persist after the initial neonatal period
biliary atresia, hypothyroidism and G6PD deficiency
investigations for neonatal jaundice
management for neonatal jaundice
after phototherapy for neonatal jaundice which investigation should be done
Once phototherapy is complete, a rebound bilirubin should be measured 12 – 18 hours after stopping to ensure the levels do not rise about the treatment threshold again.
most dangerous side effect of neonatal jaundice
kernicterus
kernicterus definition, presentation and long term effects
SUDI usually occurs within which time frame
first six months of life
Risk factors for SUDI
Prematurity
Low birth weight
Smoking during pregnancy
Male baby (only slightly increased risk)
Measures to reduce the risk of SIDS include:
is a great charity to help support families affected by SIDS
The lullaby trust is a great charity to help support families affected. Bereavement services and bereavement counselling should be available for affected families.
…team supports parents with their next infant after a sudden infant death
The CONI team supports parents with their next infant after a sudden infant death.
This provides extra support and home visits, resuscitation training and access to equipment such as movement monitors that alarm if the baby stops breathing for a prolonged period.
Respiratory distress syndrome clinical features
Clinical features are those common to respiratory distress in the newborn, i.e. tachypnoea, intercostal recession, expiratory grunting and cyanosis
Chest xray in Respiratory distress syndrome shows
“ground-glass” appearance
Respiratory distress syndrome cause
insufficient surfactant production and structural immaturity of the lungs in premature babies
Respiratory distress syndrome pathophysiology
Inadequate surfactant leads to high surface tension within alveoli. This leads to atelectasis (lung collapse), as it is more difficult for the alveoli and the lungs to expand. This leads to inadequate gaseous exchange, resulting in hypoxia, hypercapnia (high CO2) and respiratory distress.
Respiratory distress syndrome commonly occurs in which time frame
32 weeks
Respiratory distress syndrome management
Respiratory distress syndrome complications
Milia disappears within..
Salmon patch/naevus flammeus location..worse when..
Congenital dermal melanocytosis more common in…location…differential
Erythema toxicum presentation
Transient neonatal pustular melanosis presentation
Vascular lesion/port wine stain lesions, differential
Infantile haemangioma presentation and treatment
Definition of talipes : what are the two types
Talipes equinovarus describes the ankle in which position
Talipes equinovarus describes the ankle in plantar flexion and supination.
Talipes calcaneovalgus describes the ankle in which position
Talipes calcaneovalgus describes the ankle in dorsiflexion and pronation
Talipes is treated with
“Ponseti method” with good results. Surgery may be required if the Ponseti method fails or cannot be used.
describe ponseti’s method
Positional talipes presentation and treatment
Spina bifida definition
Spina bifida is a neural tube defect characterised by incomplete development of the spinal column, resulting in herniation of the spinal cord.
3 types of spina bifida
Most common and most mild form of spina bifida and most severe form
Prevention of spina bifida
How is spina bifida diagnosed
prenatal scans
Clinical manifestations of spina bifida
Management of spina bifida
Primary neurosurgical repair
Orthopaedic surgery
Cephalohaematoma definition
A cephalohaematoma is a collection of blood between the skull and the periosteum
Cephalohaematoma cause
damage to blood vessels during a traumatic, prolonged or instrumental delivery.
It can be described as a traumatic subperiosteal haematoma.
Cephalohaematoma vs caput succedaneum
The blood is below the periosteum, therefore the lump does not cross the suture lines of the skull. This is an important way of distinguishing caput succedaneum from cephalohaematoma. Additionally, the blood can cause discolouration of the skin in the affected area.
Management and complications associated with a Cephalohaematoma
Usually a cephalohaematoma does not required any intervention and resolves without treatment within a few months. There is a risk of anaemia and jaundice due to the blood that collects within the haematoma and breaks down, releasing bilirubin. For this reason the baby should be monitored for anaemia, jaundice and resolution of the haematoma.
caput succedaneum definition
Caput succedaneum (caput) involves fluid (oedema) collecting on the scalp, outside the periosteum
caput succedaneum is caused by
Caput is caused by pressure to a specific area of the scalp during a traumatic, prolonged or instrumental delivery. The periosteum is a layer of dense connective tissue that lines the outside of the skull and does not cross the sutures (the gaps in the baby’s skull). The fluid is outside the periosteum, which means it is able to cross the suture lines
caput succedaneum management
There is usually no, or only mild, discolouration of the skin. It does not require any treatment and will resolve within a few days.
Suspected HIE in neonates when?
Causes of HIE
HIE grades (…staging)
Management of HIE
How does therapeutic hypothermia work? it reduces the risk of which complications
Small for gestational age is defined as a fetus that measures below the… for their gestational age.
below the 10th centile
Two measurements on ultrasound are used to assess the fetal size:
Estimated fetal weight (EFW)
Fetal abdominal circumference (AC)
….are used to assess the size of the fetus, based on the mother’s:
Customised growth charts are used to assess the size of the fetus, based on the mother’s:
Ethnic group
Weight
Height
Parity
Severe SGA is when the fetus is below the
3rd centile for their gestational age
Low birth weight is defined as
a birth weight of less than 2500g
The causes of SGA can be divided into two categories:
- Constitutionally small, matching the mother and others in the family, and growing appropriately on the growth chart
- Fetal growth restriction (FGR), also known as intrauterine growth restriction (IUGR)
Fetal growth restriction (FGR), also known as intrauterine growth restriction (IUGR), is when there is
when there is a small fetus (or a fetus that is not growing as expected) due to a pathology reducing the amount of nutrients and oxygen being delivered to the fetus through the placenta.
The causes of fetal growth restriction can be divided into two categories:
- Placenta mediated growth restriction
- Non-placenta mediated growth restriction, where the baby is small due to a genetic or structural abnormality
Constitutionally small, definition
Constitutionally small, matching the mother and others in the family, and growing appropriately on the growth chart
Placenta mediated growth restriction refers to
conditions that affect the transfer of nutrients across the placenta
Placenta mediated growth restriction refers to conditions that affect the transfer of nutrients across the placenta:
Idiopathic
Pre-eclampsia
Maternal smoking
Maternal alcohol
Anaemia
Malnutrition
Infection
Maternal health conditions
Non-placenta medicated growth restriction refers to
pathology of the fetus
Non-placenta medicated growth restriction refers to pathology of the fetus, such as:
Genetic abnormalities
Structural abnormalities
Fetal infection
Errors of metabolism
There may be other signs that would indicate FGR other than the fetus being SGA, such as:
Reduced amniotic fluid volume
Abnormal Doppler studies
Reduced fetal movements
Abnormal CTGs
Short term complications of fetal growth restriction include:
Fetal death or stillbirth
Birth asphyxia
Neonatal hypothermia
Neonatal hypoglycaemia
Growth restricted babies have a long term increased risk of:
Cardiovascular disease, particularly hypertension
Type 2 diabetes
Obesity
Mood and behavioural problems
There are a long list of risk factors for SGA:
Previous SGA baby
Obesity
Smoking
Diabetes
Existing hypertension
Pre-eclampsia
Older mother (over 35 years)
Multiple pregnancy
Low pregnancy‑associated plasma protein‑A (PAPPA)
Antepartum haemorrhage
Antiphospholipid syndrome
Low-risk women for SGA have monitoring of
symphysis fundal height (SFH) at every antenatal appointment from 24 weeks onwards to identify potential SGA. The SFH is plotted on a customised growth chart to assess the appropriate size for the individual woman.
If the symphysis fundal height is less than the 10th centile, women are booked for serial growth scans with umbilical artery doppler.
If the symphysis fundal height is less than the… centile, women are booked for… to assess for SGA
If the symphysis fundal height is less than the 10th centile, women are booked for serial growth scans with umbilical artery doppler.
Women are booked for serial growth scans with umbilical artery doppler to assess for SGA/FGR if they have:
- Three or more minor risk factors
- One or more major risk factors
- Issues with measuring the symphysis fundal height (e.g. large fibroids or BMI > 35)
Women at risk or with SGA are monitored closely with …measuring:
- Estimated fetal weight (EFW) and abdominal circumference (AC) to determine the growth velocity
- Umbilical arterial pulsatility index (UA-PI) to measure flow through the umbilical artery
- Amniotic fluid volume
Ultrasound frequency to monitor for SGA is increased where there is
reduced growth velocity or problems with umbilical flow
An example regime for serial growth scans for women at risk of SGA is
growth scan every four weeks from 28 weeks gestation
The critical management steps for SGA are:
- Identifying those at risk of SGA
- Aspirin is given to those at risk of pre-eclampsia
- Treating modifiable risk factors (e.g. stop smoking)
- Serial growth scans to monitor growth
- Early delivery where growth is static, or there are other concerns
When a fetus is identified as SGA, investigations to identify the underlying cause include:
Early delivery is considered for SGA when? This reduces the risk of…
Early delivery is considered when growth is static on the growth charts, or other problems are identified (e.g. abnormal Doppler results). This reduces the risk of stillbirth.
…are given when delivery is planned early, particularly when delivered by caesarean section
Corticosteroids
Turner syndrome definition
female has a single X chromosome, making them 45 XO. The O referrs to an empty space where the other X chromosome should be. Life expectancy is close to normal.
Features of turner syndrome
The three classic features of Turner’s to remember and look out for in exams are
short stature, webbed neck and widely spaced nipples
Turner syndrome Associated conditions
Management of Turner syndrome
Hypospadias clinical features
- a ventral urethral meatus (urethral opening on the underside of penis towards scrotum)
- This might be further towards the bottom of the glans (in 90% of cases), halfway down the shaft or even at the base of the shaft
- a hooded prepuce
- chordee (ventral curvature of the penis) in more severe forms
- the urethral meatus may open more proximally in the more severe variants. However, 75% of the openings are distally located.
Epispadias definition
Epispadias is where the meatus is displaced to the dorsal side (top side) of the penis. Usually, the foreskin is abnormally formed to match the position of the meatus.
Hypospadias vs Epispadias
Hypospadias is what type of condition? It affects which age group? How is diagnosed?
Hypospadias is a congenital condition affecting babies from birth and is usually diagnosed on the examination of the newborn.
If missed, parents may notice an abnormal urine stream.
hypospadias associated conditions
Hypospadias most commonly occurs as an isolated disorder. However, associated conditions include cryptorchidism (present in 10%) and inguinal hernia.
Hypospadias management
Hypospadias complications
- Difficulty directing urination
- Cosmetic and psychological concerns
- Sexual dysfunction
Definition of plagiocephaly and brachycephaly
- Plagiocephaly refers to flattening of one area of the baby’s head
- Brachycephaly refers to flattening at the back of the head, resulting in a short head from back to front
Cause of plagiocephaly
baby had a tendency to rest their head on a particular point, resulting in the skull bones and sutures moulding with gravity to create an abnormal head shape. This is called positional plagiocephaly.
This has become more common as parents are advised to rest babies on their back to reduce the risk of sudden infant death syndrome.
Typical presentation plagiocephaly
baby aged 3 – 6 months with an abnormal head shape. They often have a history of preferring to sleep on one side of their head.
Which condition needs to be excluded before diagnosis plagiocephaly
Exclude craniosynotosis (sutures fusing too early) with a thorough history and properly palpating the sutures. Where there is doubt refer for specialist assessment and imaging.
Which condtion can cause a child to rest only to one side when sleeping leading to plagiocephaly? how can it be treated?
Look for congenital muscular torticollis (CMT), which is a shortening of the sternocleidomastoid muscle on one side. This may be the reason the child always rests on one side of their head.
Physiotherapy can help with movement exercises to treat the torticollis.
Management of plagiocephaly
Cleft lip definition
Cleft lip is a congenital condition where there is a split or open section of the upper lip. This opening can occur at any point along the top lip, and can extend as high as the nose.
Cleft palate definition
Cleft palate is where a defect exists in the hard or soft palate at the roof of the mouth. This leaves an opening between the mouth and the nasal cavity. Cleft lip and cleft palate can occur together or on their own.
3 in 10 cases of cleft lip or palate are associated with
another underlying syndrome.
Cleft palate and lip complications
- significant problems with feeding, swallowing and speech.
- significant psycho-social implications, including affecting bonding between mother and child.Surgery generally resolves these problems.
- Children with cleft palates can be more prone to hearing problems, ear infections and glue ear.
management of cleft lip and palate
definitive treatment is to surgically correct the cleft lip or palate. This leaves a subtle scar, but is generally very successful, giving full functionality to the child.
Cleft lip surgery is usually performed at 3 months, whilst cleft palate surgery done at 6 – 12 months.
Congenital adrenal hyperplasia is caused by…this as a consequence leads to…
Congenital adrenal hyperplasia is inherited in which pattern autosomal dominant or recessive?
autosomal recessive
Glucocorticoid hormones action
Glucocorticoid hormones act to help the body deal with stress, raise blood glucose, reduce inflammation and suppress the immune system
cortisol is what type of hormone?
Cortisol is the main glucocorticoid hormone
How do cortisol levels change throughout the day?
The level of cortisol fluctuates during the day, with higher levels in the morning and during times of stress.
Cortisol is released in response to…
in response to adrenocorticotropic hormone (ACTH) from the anterior pituitary.
Mineralcorticosteroids act on which body part? What is their action?
Mineralocorticoid hormones act on the kidneys to control the balance of salt and water in the blood
Aldosterone is what type of hormone?
Aldosterone is the main mineralocorticoid hormone
Aldosterone is released by… in response to…
released by the adrenal gland in response to renin
Aldosterone action
Aldosterone acts on the kidneys to increase sodium reabsorption into the blood and increase potassium secretion into the urine.
Therefore, aldosterone acts to increase sodium and decrease potassium in the blood.
21-hydroxylase is the enzyme responsible for converting
21-hydroxylase is the enzyme responsible for converting progesterone into aldosterone and cortisol.
Progesterone is also used to create testosterone, but this conversion does not rely on the 21-hydroxylase enzyme
Congenital adrenal hyperplasia pathophysiology
Congenital adrenal hyperplasia presentation in severe cases
Congenital adrenal hyperplasia presentation in mild cases
A textbook and exam clue that a patient has CAH is
TOM TIP: A textbook and exam clue that a patient has CAH is skin hyperpigmentation. Hyperpigmentation occurs because the anterior pituitary gland responds to the low levels of cortisol by producing increasing amounts of ACTH. A byproduct of the production of ACTH is melanocyte simulating hormone. This hormone stimulates the production of melanin (pigment) within skin cells.
CAH management
definition of neonatal hypoglycaemia
< 2.6 mmol/L
Persistent/severe neonate hypoglycaemia may be caused by:
preterm birth (< 37 weeks)
maternal diabetes mellitus
IUGR
hypothermia
neonatal sepsis
inborn errors of metabolism
nesidioblastosis
Beckwith-Wiedemann syndrome
Transient hypoclyacemia cause
Transient hypoglycaemia in the first hours after birth is common
neonatal hypoglycaemia features
neonatal hypoglycaemia management
NICE recommend that APGAR scores are routinely assessed at…of age
NICE recommend that APGAR scores are routinely assessed at 1 and 5 minutes of age
APGAR score stands for and what are the different measurements?
APGAR is an mnemonic for the assessment of:
Appearance (colour)
Pulse (heart rate)
Grimace (reflex irritability)
Activity (muscle tone)
Respiratory effort
Maternal… use during pregnancy can cause orofacial clefts
Maternal anti-epileptic use during pregnancy can cause orofacial clefts
…is the most likely cause of worsening neurological function in a premature infant born at 34 weeks gestation.
Intraventricular haemorrhage (IVH) is the most likely cause of worsening neurological function in a premature infant born at 34 weeks gestation.
Neonatal sepsis should be considered in infants with vague signs such as
poor feeding, grunting,lethargy
Foetal alcohol syndrome features
Necrotising enterocolitis features
AXR findings in necrotisng enterocolitis
Necrotising enterocolitis investigation for diagnosis
AXR
most common presentation of neonatal sepsis
Grunting and other signs of respiratory distress
When is the neonatal blood spot screening test typically performed in the United Kingdom
Between fifth and ninth day of life
which conditions are screened for in the neonatal blood spot test in the UK?
The following conditions are currently screened for:
congenital hypothyroidism
cystic fibrosis
sickle cell disease
phenylketonuria
medium chain acyl-CoA dehydrogenase deficiency (MCADD)
maple syrup urine disease (MSUD)
isovaleric acidaemia (IVA)
glutaric aciduria type 1 (GA1)
homocystinuria (pyridoxine unresponsive) (HCU)
what is infantile colic? age of presentation
Infantile colic describes a relatively common and benign set of symptoms seen in young infants. It typically occurs in infants less than 3 months old and is characterised by bouts of excessive crying and pulling-up of the legs, often worse in the evening.
Infantile colic occurs in up to 20% of infants. The cause of infantile colic is unknown.
As per the NICE guidelines if any of the following are observed after any degree of meconium, then baby must be assessed by the neonatal team;
As per the NICE guidelines if any of the following are observed after any degree of meconium, then baby must be assessed by the neonatal team;
* respiratory rate above 60 per minute
* the presence of grunting
* heart rate below 100 or above 160 beats/minute
* capillary refill time above 3 seconds
* temperature of 38°C or above, or 37.5°C on 2 occasions 30 minutes apart
* oxygen saturation below 95%
* presence of central cyanosis
Perform the following investigations in infants younger than 3 months with fever:
Perform the following investigations in infants younger than 3 months with fever:
Full blood count
Blood culture
C-reactive protein
Urine testing for urinary tract infection
Chest radiograph only if respiratory signs are present
Stool culture, if diarrhoea is present
