Sick Term Infant Flashcards
when is the neonate period
first 28 days of life
what are the most common causes of neonate and later deaths in babies
neonate:
prematurity
birth asphyxia and trauma
pneumonia and sepsis
1-59 months
pneumonia
conditions
non communicable diseases
what are the components of the apgar score
heart rate (absent -> <100 -> >100) resp effort (absent -> weak irregular gasping -> strong cry) tone (none -> some flexion -> flexed arms and legs that resist extension) colour (blue/ pale -> blue extremities -> normal) response (none -> grimace/ feeble cry when stimulated -> cry/ pull away when stimulated)
(0 ->1 -> 2, scored out of ten)
when might a neonate become unwell
at delivery
after 1st few hours
first days
up to 28 days
what are the components of a newborn clinical exam
Hx- maternal (PMHx, pregnancy, drugs, infection risks) and infant (fetal growth, fetal anomaly, delivery, resuscitation)
inspection (tone, level of arousal, colour)
vital signs (HR, RR)
work of breathing and resp effort (subcostal recession, indrawing, apnoea)
cap refill 2-3 seconds
O2 sats (>95%)
check for jaundice, sezures, poor feeding, bilious vomit
why is level of cyanosis not a good predictor of O2 sats
as need sats less than 80 to get this so might miss a lot of low sats if relying on colour
what is normal newborn resp rate
40-60
what is normal newborn HR
120-140
120-160 if newborn
how might a baby having a seizure present
lip smacking
eye rolling
cycling movements of legs
apnoea
why do pre term babies get apnoea
forget to breath as resp centres in brain not mature
what temperature should babies be
36.5-37.4
what happens to babies when glucose metabolism abnormal
means surfactant cant work properly so get hypoglycaemia and resp distress
how much is a babies blood volume
80ml/kg
should you wait to give a baby antibiotic
no give asap unti you are sure its not infection causing illness
what might babies need to improve circulation
fluid and inotropes
how do you support the babies airway
head in neural position- some evidence oxygen is harmful so only given if needed
ventilation
what is the role of therapeutic cooling
when there has been significant brain damage this can prevent further damage or ischaemia- prevents cerebral palsy
what are the 4 categories of causes of a sick baby
pregnancy/ birth related
metabolic
infection
congenital abnormalities
what are the likely causes of ante, peri and post natal infections
ante- bacterial (worry about mothers who are strep a carriers)
peri- viral
post- fungal (unlikely unless in intensive care)
what makes antenatal infection more likely
premature rupture of membranes
what are the sites of infection in a newborn
blood stream (bacteraemia) CNS- meningitis resp- pneumonia GU- UTI (more common in boys) skin bone- osteomyelitis GI- necrotising enterocolitis
what bacterial infections are common in newborns
group B strep (most common) e coli listeria myocytogenes staph aureus staph epidermis (babies who have had surgery/ procedure done)
what viral infections are common in newborns
CMV
parvovirus
herpes
enterovirsuses
toxoplasma gondii
HIV
syphilis (treponema pallidum)
TORCH
what is hypoxic ischaemic encephalopathy
multi organ damage due to tissue hypoxia (peri natal asphyxia)
will have poor apgar score and need active resus
neurodevelopmental sequeli
what will be seen on x ray in transient tachypnoea of the newborn
white lungs with fluid in the horizontal fissure
what are the resp complications of pregnancy/ birth
pneumothorax TTN Resp distress syndrome infection/ sepsis pneumonia
what are cardiac complications of pregnancy/ birth
Heart failure:
-Hydrops foetalis
(caused by: Rhesus disease (happens because baby is extremely anaemic), Chromosomal or Idiopathic (50%))
Failure to adapt to postnatal life:
-Persistent Pulmonary Hypertension of the Newborn (PPHN)- BP in lungs stays high so blood doesn’t go to them and get oxygenated
what are the features of hydrops fetalis
abnormal fluid accumulation in two or more fetal compartments. These may include ascites, pleural effusion, pericardial effusion and skin oedema, hepatomegaly. It may also be associated with polyhydramnios and placental oedema.
list the congenital cardiac diseases
Tetralogy of Fallot Transposition of great arteries Coarctation of the aorta TAPVD (Total Anomalous Pulmonary Venous Drainage- not connected to LA) Hypoplastic heart
how do congenital heart defects present
cyanosis, murmurs, tachpnoea
what congenital resp problems can occur
Tracheo-oesophageal fistula (on x ray NG tube curled up, no stomach bubble. babies will be slavery and have blue episodes) Diaphragmatic hernia (bowel in lung cavity)
what is potters syndrome
renal congenital anomlies renal agenesis (cant produce urine, reduced amniontic fluid, pulmonary hypoplasia)
name a MSK congenital anomaly
myotonic dystophy
what can cause newborn hypoglycaemia
related to reduced “reserves” - LBW/SGA
related to maternal disease - IDM
evidence of more complex metabolic disorder
what factors are the most influential to a babies weight
IU conditions (rather than mothers height)
what tests determine the risk of hepatitis transmission
Viral load- if no viral load and antibodies then previously infected
IgM levels
is hep C transmitted in breast milk
no regardless of viral load- UNLESS nipples are chapped
are methodone and valium CI in breast feeding
no
why are new born at risk of heat loss
Large head Large surface area to volume Pre term thin epithelium Wet Naked Can’t shiver
simple measures can be done to prevent heat loss in babies
Hat on Shut windows Skin to skin Warmed blankets If still cold can use heated mattress (only put baby in baby grow when on this as heat wont get to baby if has lots of layers on)
what classifies as neonatal hypoglycaemia
BM <2.6
how might hypoglycaemia present
Hypothermia abnormal Feeding behaviour Infection/sepsis Lethargy Jitteriness Seizure activity apnoea cyanosis hypotonia high pitched cry
how do you prevent hypoglycaemia
Keep baby warm and dry 36.6°C - 37.2°C
Early feed (within 1 hour)
Minimal Handling
Consider environment/stressors
what are the risk factors for hypoglycaemia
preterm weight <2nd centile diabetic mother maternal labetolol >2 doses perinatal acidosis (cord pH <7.1 + BE >-12mmol/l) more likely to happen when infant cold
what is the management for asymptomatic babies at risk of hypoglycaemia
check pre feed b, prior to 2nd feed 2-4 after birth
record on NEWs with vital signs
if breast feeding no more than 3 hours between feeds
if formula 10-15mls 3 hourly
check pre feed glucose before 3rd feed
how do you treat asymptomatic hypoglycaemia
consider buccal dextrose gel
support breast feeding
if fomrula 10-15mls 3 hourly
check pre 3rd feed glucose
how do you treat symptomatic hypoglycaemia
urgent neonate review
buccal dextrose if bm <2.6
feed 3 hourly
check pre 3rd feed glucose
if doesnt improve call neonate team who will sens urgent lab /analyser glucose
repeat bucaal dextrose gel as part of feeding plan
may require admission to NMU
how do you treat symptomatic hypoglycaemia
urgent neonate review
buccal dextrose if bm <2.6
feed 3 hourly
check pre 3rd feed glucose
if doesnt improve call neonate team who will sens urgent lab /analyser glucose
repeat bucaal dextrose gel as part of feeding plan
may require admission to NMU
of BG<1 IV glucose
what are the indications for oral dextrose gel
BG <1
signs of hypoglycaemia
BG 1-2.6 with no clincal signs
what must be considered in the administration of oral dextrose gel
infant must be 35 weeks gestation and younger than 48 hours
must be used in conjunction with feeding plan
how is oral dextrose given
0/5 ml/kg up to two doses given 30 mins apart
max of 6 doses in 48 hours
dry mucosa with gauze
squirt gel onto cheel with oral syringe and massage with latex fee gloves
offer feed immediately afterwards
what should you do if there are 2 consecutive bm >2.6
stop measuring unless clinically indicated
what is heme converted to before bilirubin
bilverderin
what are the causes of neonatal jaundice
physiological blood group incompatability (rhesus/ ABO) haemolytic disorders sepsis liver disease metabolic disorders
why does physiological jaundice happen
Increased production of bilirubin (haemolysis of fetal RBC)
Decreased uptake and binding by liver cells
Decreased conjugation(most important)
Decreased excretion
Increased enterohepatic circulation of bilirubin
when is jaundice pathological
<24 hours of age
when bilirubin are too high and require treatment
lasting more than 10 days, esp more than 2 weeks
what causes jaundice <24 hrs after birth
haemolysis:
-ABO incompatibility
-Rh immunisation
-Sepsis
hepatitis (will have substantial elevation of conjugated bilirubin (>15% of the total))
red cell enzyme defects e.g. G6PD deficiency
red cell membrane defects, e.g. hereditary spherocytosis
how do you investigate early pathological jaundice
Total and conjugated serum bilirubin concentration (SBR)
Maternal blood group and antibody titres (if Rh negative)
Baby’s blood group, direct antiglobulin (Coombs) test (detects antibodies on the baby’s red cells), and elution test to detect anti-A or anti-B antibodies on baby’s red cells (more sensitive than the direct Coombs test)
Full blood examination, looking for evidence of haemolysis, unusually-shaped red cells, or evidence of infection
CRP might assist with diagnosis of infection
what can cause very high levels of bilirubin= pathological jaundice days 1-10
Mild dehydration/insufficient milk supply (breast-feeding jaundice)
Haemolysis
Breakdown of extravasated blood (e.g. cephalhaematoma, bruising, CNS haemorrhage, swallowed blood)
Polycythaemia (increased RBC mass)
Infection - a more likely causeduring this time
Increased enterohepatic circulation (e.g. gut obstruction)
what can cause persistent unconjugated hyperbilirubinaemia
Breast milk jaundice (diagnosis of exclusion, cessation not necessary)
Continued poor milk intake
Haemolysis
Infection (especially urinary tract infection)
Hypothyroidism
what can cause persistent conjugated hyperbilirubinaemia
ALWAYS ABNORMAL
hepatitis- infection, metabolic disease
biliary atresia (pale stools and dark urine)
what is kernicterus
Unconjugated bilirubin is toxic to the brain and can cross blood brain barrier
characterised by the death of brain cells and yellow staining, particularly in the grey matter
=the permanent clinical sequelae of bilirubin toxicity
what are the signs of acute bilirubin encephalopathy include (kernicterus)
lethargy poor feeding temperature instability hypotonia arching of the head, neck and back (opisthotonos) spasticity seizures
what increases the risk of developing kernicterus
Increasing unconjugated bilirubin - concentrations greater than 340 micromol/L
Decreasing gestation
Asphyxia, acidosis, hypoxia, hypothermia, meningitis, sepsis, and decreased albumin binding
what Tx for jaundice
treat cause
re hydrate (milk not water, IV fluids if needed)
phototherapy
exchange transfusion
IV immunoglobulin for isoimmune haemolytic disease
what is the course of physiological jaundice
Onset day 2
Peak day 3
Resolve by day 10-14
Otherwise well infant
what are the perinatal risk factor for sepsis
group B strep colonisation PROM group b strep bacteriuria during pregnancy high maternal temp during labour chorioamnionitis sustained intrapartum fetal tachycardia previous child born with infection
what is the physical appearance of a neonate with sepsis
resp distress: -grunting -retractions -pallor/cyanosis pallor: -hypotension -delayed cap refill -hypoxia lethargy: -poor feeding -indifferent to pain vital signs: -tachy pnoea and cardia -hypotension -temp high/low/normal
what Ix for neonate sepsis
blood culture
LP
urine culture
blood sugar
FBC (low WBC, look for anaemia due to haemolytic disease also)
CRP (>4)
U&Es (can get hyponatraemic in sepsis)
what organisms usually causes neonatal sepsis
group B strep e coli staph aureus enterococcus staph epi klebsiella listeria
what is the treatment for neonate sepsis
if newly delivered:
Benzylpenciliin
Gentamicin
if got sepsis from hospital in NICU with central catheters:
Vancomycin/Flucloxacillin (Staph)
what are the features of neonate withdrawal
continuous/ excessive high pitched cry reduced sleep after feeds tremor increased muscle tone generalised convulsing frantic fist sucking poor feeding regurgitation projectile vomiting loose stools/ diarrhoea frequent yawning sneezing mottling high temo high resp rate indrawing excoriations
what score to evaluate fetal withdrawal
neonatal abstinence score
when do you start treatment for neonatal withdrawal
An infant with 3 consecutive scores on NAS, averaging more than 8 should be commenced on
treatment (and therefore admitted to SCBU), scoring should be 4 hourly
how does phototherapy work to treat jaundice
Blue light, 420-470 nm wavelength
Photo-isomerization of bilirubin
converts trans-bilirubin to the more water soluble cis-form which is excreted in the bile without conjugation.
Photosensitised oxidisation
what are the side effects of phototherapy
dehydration
skin rash
eye damage
when in jaundice prolonged
2 weeks if term
3 weeks if pre term
what Ix for jaundice
FBC/LFTS/SBR/TFTS
Serum bilirubin if within 24hrs of life/ <35 weeks gestation
transcutaneous bilirubinometer if over 35 weeks
blood grouping
what is it important to ask about in a jaundice Hx
Feeding Weight loss Family Hx Stool/Urine Behaviour Organomegaly
what can cause conjugated jaundice
Biliary atresia total parentral nutrition Hypothyroidism α1 Antitrypsin Galactosaemia Cystic Fibrosis Trisomy 21 Dubin Johnson Alagille Syndrome
what can cause unconjugated jaundice
Physiological Breast Milk Haemolysis Infection Inherited causes Intestinal obstruction
what is the course of breast milk jaundice
develops after day 4 or day 7, peaks toward end of 2nd week of life
what are the metabolic causes of resp distress
Acidosis, Inborn errors of metabolism, hypoglycaemia
what are the haematological causes of resp distress
Polycythaemia, Blood loss/anaemia
what are the cardiac causes of resp distress
congenital heart disease
PPHN
what are the neuro causes of resp distress
Seizures, Intracranial bleed, Withdrawl
what are the anatomical causes of resp distress
CCAM (Congenital Cystic Adenomatoid Malformation)
Chest wall deformities, diaphragmatic hernia, TOF
what is the management for resp distress
Suction = yankauer, fine bore suction catheter (mouth and nose)
Airway opening maneuvres = head tilt to neutral position, jaw thrust. Be careful not to make matters worse by pressing on soft submandibular/submental tissues.
Respiratory support, surfactant, stop feeds, antibiotics
Ix and Rx underlying cause
how are most babies with hypoglycaemia asymptomatic
as can use ketones as brain fuel
how can you minimised the affects of NAS
Reduce noise, bright lights, regular feeding (breast milk if possible)
Dressed appropriately, swaddle (only top half as don’t want DDH)
Containment hold- gentle pressure of hands, not bouncing them, Is more calming in abstinence syndrome
what medications are used in the Tx of NAS
Opiate given to baby if mum on methadone/ opiates
Benzos if mum was on them or was on a lot of polypharmacy
Phenobarbitone if babies very distressed
what weight loss is normal after birth
up to 10%
what does the Guthrie Card/Newborn Screening card screen for
Cystic fibrosis (immunoreactive trytin screened for) Thyroid function testing (TSH measured) Haemoglobinopathies Metabolic disease phenylketonuria (PKU)
what are anaemic babies given when discharged
folic acid
what treatment for biliary atresia
surgery to loop duodenum onto liver so bile flows from liver into bowel, good outcomes in 90% if done before 8 weeks of life, if done after 8 weeks then almost all need liver transplant
why is vitamin K given
to prevent haemorrhagic disease of the newborn
what are all day 5 babies screened for
congenital hypothyroidism PKU CF heamoglobinopathies MCAD
