Peer Teaching Notes Flashcards
What is the bilirubin cycle?
- Hb broken down to unconjugated bilirubin (haemolysis)
- Unconjugated bilirubin + albumin-> insoluble in water
- Travels to liver-> where conjugated
- Conjugated soluble + excreted by small intestine or into liver then back to blood (come out via kidneys)
What are pathological causes of jaundice that present within 24 hours of life?
- Haemolytic disease of the newborn (rhesus disease)
- ABO incompatibility
- Red cell anomalies-> G6PD, congenital spherocytosis
- Congenital infection-> TORCH
- Haematoma
What are the congenital diseases listed by the TORCH mnemonic?
- Toxoplasmosis
- Other-> syphilis, varicella, mumps, parvovirus, HIV
- Rubella
- Cytomegalovirus
- Herpes simplex
What are pathological causes of jaundice that present between 24 hours and 14 days of life?
- Increased bilirubin due to shorter RBC lifespan
- Decreased conjugation by immature hepatocytes
- Absence of gut flora-> impede elimination of bile pigment
- Breastfeeding
What are pathological causes of jaundice that present for over 14 days in neonates (prolonged jaundice) and are due to unconjugated bilirubin?
- Sepsis-> UTI, meningitis
- Breastfeeding
- Hypothyroidism
- Neonatal hepatitis
- Hepatic enzyme deficiency
- Enclosed bleeding
What are pathological causes of jaundice that present for over 14 days in neonates (prolonged jaundice) and are due to conjugated bilirubin?
- Sepsis-> TORCH
- TPN
- Galactosaemia
- Cystic fibrosis
- Alpha-1 antitrypsin deficiency
- Biliary atresia
When is jaundice in neonates always pathological?
If presents within <24 hours of life
What is the pathophysiology of haemolytic disease of the newborn?
- RhD -ve mum delivers RhD +ve baby
- Leak of foetal red cells into her circulation may cause production of anti-D IgG antibodies-> isoimmunisation
- Sensitisation events-> threatened miscarriage, APH, mild trauma, amniocentesis, CVS, ECV
- Subsequent pregnancy-> cross placenta + cause disease
What are some sensitisation events that can trigger haemolytic disease of the newborn?
Threatened miscarriage, APH, mild trauma, amniocentesis, CVS, ECV
How is haemolytic disease of the newborn detected?
- Screening-> indirect Coombs test
- D-antibodies-> identify -ve mums who aren’t sensitised and stop disease from happening
When is anti-D given in pregnancy?
- 28 weeks +/- 34 weeks
- Contains antibodies-> get rid of +ve antigens in blood before mum produces own
- May be given after sensitising events
What should happen if mum is rhesus -ve but already has antibodies?
- Monitor antibody level
- US baby-> check complication signs
- Take blood from baby-> anaemia + need for transfusion
What are the serious complications of haemolytic disease of the newborn?
- Hydrops fetalis
- Polyhydramnios
- Post natal-> SC oedema, pericardial effusion, pleural effusion, ascites, hepatosplenomegaly
What is hydrops fetalis?
Often life-threatening condition in which foetus has excess fluids around the heart, liver and abdomen
How might neonatal jaundice be investigated?
- FBC
- Enzyme assays
- Blood film
- Infection screening
- Direct Coombs test
- Transcutaneous bilirubin
- LFTs
- Serum bilirubin
- TORCH screen
- Blood group
How might neonatal jaundice be managed?
- UV phototherapy
- Exchange transfusion
What is the definition of full term?
40 weeks
What is the definition of premature?
<37 weeks
What is the definition of low birth weight?
<2500g
What is the definition of very low birth weight?
<1500g
What is the definition of extremely low birth weight?
<1000g
What is the definition of small for gestational age?
Weight below 10th centile at any gestational age
What is symmetrical intrauterine growth restriction?
All growth parameters are symmetrically small
What is asymmetrical intrauterine growth restriction?
Weight centile is less than length + head circumference centile
What causes symmetrical intrauterine growth restriction?
- Insult in early pregnancy
- Chromosomal abnormalities
- Constitutionally small
What causes asymmetrical intrauterine growth restriction?
- Insult late in pregnancy
- Placental insufficiency
What type of intrauterine growth restriction is higher risk?
Asymmetrical
What can cause a baby to be small for gestational age?
- Poverty
- Twins
- Small parents
- Congenital infection
- Constitutionally small
- Placental insufficiency
- Smoking
- Hypertension
- CVD
- Diabetes
- Pre-eclampsia
What can cause prematurity?
- Unknown
- PMH of prematurity
- Malnutrition
- Poverty
- Smoking
- GU infection
- Chorioamnionitis
- Pre-eclampsia
- Polyhydramnios
- Twins
- Diabetes
- Uterine malformation
- Placenta praevia/abruption
- PROM
- Accidentally induced labour
How should a baby born very prematurely (eg 27 weeks) be managed?
- Paediatrician must be present
- Room at 26 degrees
- Don’t dry baby
- Put under heaters
- Place in plastic bag
What are the components of the APGAR score?
- Appearance (skin colour)
- Pulse rate
- Grimace reflex
- Activity (muscle tone)
- Respiration
What are the different scores for the components of APGAR?
- Appearance (skin colour)-> blue/pale all over (0), blue at extremities (1), no cyanosis (2)
- Pulse rate-> absent (0), <100bpm (1), >100bpm (2)
- Grimace reflex-> no response to stimulation (0), grimace on suction/aggressive stimulation (1), cry on stimulation (2)
- Activity (muscle tone)-> none (0), some flexion (1), flexed arms + legs that resist extension (2)
- Respiration-> absent (0), weak/irregular/gasping (1), strong + robust cry (2)
What is respiratory distress syndrome?
Lack of surfactant causes respiratory issues in newborn
What are the signs of respiratory distress syndrome?
- Grunting
- Head bobbing
- Tachypnoea
- Intercostal recession
- Nasal flaring
How is respiratory distress syndrome managed?
- Intrapartum steroids (dexa or betamethasone)-> help lungs develop
- Delayed cord clamping
- Oxygen
- Intubate + ventilate if needed
- Surfactant-> down ET tube
How much fluids are neonates typically prescribed for a bolus?
20ml/kg
How are maintenance fluids calculated and prescribed in paeds?
- 100ml/kg/day for first 10kg weight
- 50ml/kg/day for second 10kg of weight
- 20ml/kg/day for weight over 20kg
How much maintenance fluids would a 45kg 12 year old girl be prescribed?
- 100ml x 10kg= 1000ml
- 50ml x 10kg = 500ml
- 20ml x 25kg = 500ml
- 2000mls in 24 hours = 83ml/hour
What are some differentials for a collapsed neonate?
- Hypoglycaemia
- Hypothermia
- Sepsis
- Dehydration
- Coronary Heart Disease
What would a normal LP result consist of?
- Pressure 5-20
- Looks normal
- Protein normal
- Glucose normal
- Gram stain normal
- WCC normal
What would a bacterial LP result consist of?
- High pressure
- Turbid/cloudy
- High protein
- Low glucose
- Positive gram stain (usually)
- High WCC
What would a viral LP result consist of?
- Normal or mild increased pressure
- Clear appearance
- Low/normal protein
- Glucose normal
- Normal gram stain
- High glucose CSF:serum ratio
- WCC high
What would a fungal/TB LP result consist of?
- Fibrin web appearance
- Low to normal protein
- Low glucose
- High WCC
- Monocytes
What is an example of a group B streptococcus?
Strep agalactiae-> gram positive
How is group B streptococcus infection transmitted?
Colonise vaginal + GI tracts in healthy women-> can give to baby through birth
What is the most frequent cause of early onset (<7 days) infection in neonates?
group B streptococcus
What are the signs and symptoms of group B streptococcus infection?
- Temperature change
- Tachycardia
- Respiratory-> grunting, nasal flaring, accessory muscles, tachypnoea, apnoea
- Behaviour-> poor/reduced feeding, lethargy
- Skin-> rash, mottled, jaundice
- Abdominal-> vomiting, abdo distension, diarrhoea, abdo pain, knees up to chest
What is pre-natal group B streptococcus infection (GBS)?
Baby infected during pregnancy
What is early onset group B streptococcus infection (GBS)?
Infected within first week of life
What is late-onset group B streptococcus infection (GBS)?
Infected with GBS after 1 week to several months of age
How is group B streptococcus infection managed?
- Intrapartum antibiotic prophylaxis
- Testing when RFs present + infection
- Aware of GBS +ve mums-> monitor for risks, 14 days antibiotics, observation, head circumference measurement
Differential diagnoses for non-blanching rash?
- Sepsis
- Meningococcal septicaemia
- Non-accidental injury
What are the risk factors for Non-accidental injury?
- Birthweight <2500g
- Maternal age <30
- Unwanted pregnancy
- Stress
- Poverty
When should Non-accidental injury be suspected?
- Disclosure by child
- Odd incongruous story
- Delayed presentation
- Multiple presentation with injuries
- History inconsistent with child’s development
- Efforts to avoid exam
- Unexplained fractures
- Any injury in baby
- Buttock or perineum injury
- Facial injury-> torn lingual frenulum, retinal haemorrhage, bulging fontanelle
- Cigarette burns
- Finger mark bruising (petechiae)
- STIs
What investigations could be done in suspected Non-accidental injury?
- Skeletal survey
- Coagulation
- CT/MRI head
- Ophthalmology
What is the definition of weight faltering?
Weight falling through centile spaces, low weight for height or no catch-up from low birth weight
What is the definition of growth faltering?
- Crossing down through length/height centiles as well as weight
- Low height centile or less than expected from parental
What can cause faltering growth?
- Increased requirement
- Inadequate retention of food
- Impaired suck/swallow
- Psychosocial deprivation
- Inadequate availability of food
- Chronic illnesses leading to anorexia
- Malabsorption
- Failure to utilise nutrients
What are some investigations for FTT?
- FBC
- Urinalysis
- U+Es
- LFTs
- Coeliac screen
- Sweat test (CF)
What can cause a positive sweat test?
- Cystic fibrosis
- Malnutrition
- Adrenal insufficiency
- Hypothyroidism
- Hypoparathyroidism
- G6PD
What does the neonatal blood spot test screen for?
- Cystic fibrosis
- Congenital hypothyroidism
- Sickle cell disease
- 6 inborn errors of metabolism-> inc phenylketonuria
When is the neonatal blood spot test done?
Between day 5 and 8 of life
What happens after a neonatal blood spot test?
- Affected-> direct referral to paeds
- Get all results within 6 weeks
- Recorded in red book
What are the investigations for cystic fibrosis?
- Genetic tests
- Sweat test-> high chloride + low sodium
- Sinus X ray + CT
- CXR
- CT thorax
- Spirometry
- Sputum microbiology
What causes cystic fibrosis?
Mutation on CFTR gene on chromosome 7
What effect does cystic fibrosis have?
Dehydration of secretions affecting systems relying on these eg lungs + pancreas
What mode of inheritance is cystic fibrosis?
Autosomal recessive
What effects does cystic fibrosis have on the lungs?
- Thick mucous-> chronic inflammation + infections
- Neutrophilic airway inflammation
- Organisms-> s.aureus, H.influenzae, S.pneumoniae, P.aeruginosa
What are some of the signs of cystic fibrosis?
- Clubbing
- Crackles
- Wheeze
- Cyanosis
- Frequent infections
- FEV1-> obstructive
- Meconium ileus
How is cystic fibrosis managed?
- Avoid other CF patients-> may spread infections
- Lung physio-> 3x daily
- Exercise
- Prophylactic antibiotics-> double dose if unwell
- High calorie + high fat diet
- Creon-> enzymes for digestion
- Lung transplant
How does cystic fibrosis affect the GI system?
- Malabsorption-> need more energy through food
- Steatorrhoea-> malabsorption
- Thickened pancreas secretions-> block movement of enzymes + cause damage to pancreas (‘itis)
- Atrophy + progressive fibrosis of exocrine glands
- Neonates-> meconium ileus, rectal prolapse
Which vitamins are fat soluble?
ADEK
What are some complications of cystic fibrosis?
- GI obstruction
- Impaired glucose tolerance
- GI obstruction
- Liver failure
- Osteoporosis
- Fragility fractures
