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Y4 Neonatology > Sick-term infant > Flashcards

Sick-term infant Flashcards

1
Q

Define the neonatal period

A

0-27days old

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2
Q

What are the warning signs of a sick infant ?

A
  • Not feeding well
  • Convulsions
  • Drowsy or unconcious
  • Movement only when stimulated or no movement at all
  • Tachypnoea (>= 60)
  • Grunting
  • Accessory muscles used
  • Raised temp >= 38
  • Hypothermia < 35.5
  • Central cyanosis
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3
Q

What is the emergency management of a neonate and the treatment given ?

A
  • ABC - use a nasal cannula if O2 sat ≤ 90%, use bag & mask ventilation if aponea, gasping or RR < 20
  • IV access
  • IV antibiotics - is pyrexia of unknown source give GAM, if suspected menigococcal septicaemia follow meningitis treatment (in preterm lecture)
  • If drowsy or convulsing check BG - give IV glucose if needed
  • If convulsing - 1st line = phenobarbitol, 2nd line = phenytoin
  • Admit & monitor + further investigations if needed
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4
Q

What are the main causes of convulsions or fits in infants ?

A
  • Hypoxic ichaemic encephalopathy (result of perinatal asphyxia)
  • CNS infection e.g. meningitis/ encephalitis
  • Hypoglycaemia
  • Hypocalcaemia
  • Itrancranial haemorrhage
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5
Q

Define what hypoxic ischaemic encephalopathy is

A

This is where the babies O2 supply was interupted at birth, this can then result in neurodevelopmental problems in the future e.g. cerebral palsy

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6
Q

What are the symptoms of hypoxic ischaemic encephalopathy?

A
  • Hyperalert or decreased conciousness
  • Irritable
  • Eye rolling
  • Convulsions/fits
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7
Q

What is the treatment of hypoxic ischaemic encephalopathy?

A

May need mild hypothermia/cooling treatment & need to be admitted to NICU where they may have ventilation or CPAP

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8
Q

Define hypoglycaemia in neonates

A

≤ 2.5

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9
Q

What are the symptoms of hypoglycaemia in neonates ?

A
  • Coma or decreased conciousness
  • Convulsions
  • Transient hypermesis (vomiting)
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10
Q

What is the treatment of hypoglycaemia in neonates ?

A

IV glucose infusion

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11
Q

Define hypocalcaemia in neonates

A

< 2.1 (norm is 2.1-2.6)

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12
Q

What are the symptoms of hypocalcaemia in neonates ?

A
  • Convulsion/fits - muscle spasms
  • Prolonged QT interval
  • Laryngospasm
  • Bronchospasm
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13
Q

What is the treatment of hypocalcaemia in neonates ?

A
  • 1st line = Low PO43- + calcium gluconate
  • If also have hypomagnesaemia the give IV MgSO4
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14
Q

What are the 4 main serious infections in neonates ?

A
  1. Sepsis
  2. Meningitis
  3. Pneumonia
  4. UTI
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15
Q

What are the signs of sepsis in neonates ?

A
  • Seizures
  • Stiff limbs
  • Cyanosis - looks mottled, blueish or pale
  • Cap refill ≥ 3 secs
  • Difficulty feeding
  • Severe chest indrawing
  • Temp ≤ 35.5 or ≥ 37.5
  • Movement only when stimulated
  • RR ≥ 60
  • Lethargy
  • Grunting

Sepsis should always be a differential in neonates

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16
Q

In the early neonatal period (<48hrs) what is the most common causative organisms for sepsis ?

A

E.coli & Group B strep (streptococcus agalactiae)

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17
Q

In late onset sepsis alongside the common ones for early onset what are the other potential causative organisms ?

A
  • Staph. epidermis
  • Listeria monocytogenes
  • Klebsiella
  • Enterococcus
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18
Q

In suspected or confirmed sepsis of a neonate what investigations should be done as an infeciton screen to find the possible source ?

A
  • Blood culture & virology
  • CXR
  • Lumbar puncture
  • Stool sample for virology
  • Urine sample for culture & virology
  • ENT swabs for culture
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19
Q

What is the management of neonatal sepsis ?

A
  • BUFALO (Abx = GAM)
  • then once the cause is found treat as per guidelines
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20
Q

What are the 3 potential causative organsims of neonatal meningitis ?

A

Think GEL

  1. Group B strep
  2. E.coli
  3. Listeria monocytogenes
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21
Q

What are the signs/symptoms of neonatal meningitis ?

A
  • Irritable
  • High pitched abnormal cry
  • Lethargy
  • Difficulty feeding
  • Fever
  • Seizures
  • Bulging fontanelles
  • Apnoea

Note photophobia, stiff neck etc is less common in young kids

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22
Q

How is neonatal meningitis diagnosed ?

A

Lumbar puncture

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23
Q

What is the treatment of meningitis in young kids < 3months and kids > 3months ?

A
  • If < 3 months tx = cefotaxime + amoxicillin
  • If > 3months (upto age of 18) tx = 1st dose cefotazimine followed by once daily ceftriaxone + dexamethasone
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24
Q

What are the signs/symptoms of penumonia in neonates ?

A
  • Malaise
  • Poor feeding
  • Tachypnoea
  • Cyanosis
  • Grunting
  • Respiratory excessory muscle use
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25
Q

How is penumonia diagnosed in neonates ?

A

CXR + FBC + blood & sputum cultures

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26
Q

List the causes of pneumonia neonates, infants & school children ?

A
  • Neonates: GBS, E.coli, Klebsiella, Staph aureus
  • Infants: Strep pneumoniae, Chlamydia
  • School age: Strep pneumoniae, Staph aureus, Gr A strep, Bordetella, Mycoplasma, Legionella
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27
Q

How is the severity of CAP pneumonia determined ?

A

Using CURB 65

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28
Q

What is the treatment of severe and non-severe CAP in children < 1 and > 1y/o ?

A

Non severe:

  • > 1y/o 1st line = amoxicillin, 2nd line = clarithromycin
  • < 1y/o 1st line = co-amoxiclav

Severe:

  • 1st line = co-amoxiclav (+ clarithromycin if signs of atypical pneumonia or pertussis)
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29
Q

What is the treatment of HAP/post-op/aspiration penumonia in young children ?

A

1st line = co-amoxiclav

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30
Q

What are the signs/symptoms of UTI in neonates ?

A
  • Fever
  • Vomiting
  • Lethargy
  • Irritability
  • Poor feeding & failure to thrive
  • May be abdo pain, loin tenderness and other characterisitc symptoms but less likely in younger children
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31
Q

When is an upper UTI assumed in young children ?

A
  • Assumed if bacteruria & fever ≥ 38
  • OR if fever < 38 but have loin pain/tenderness & bacteriuria
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32
Q

When is lower UTI assumed in young children ?

A

Assumed in all other children who have bacteruria but no systemic symptoms/signs e.g. fever or loin pain

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33
Q

How is UTI diagnosed in young children ?

A

Clean catch urine for microscopy & culture

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34
Q

What is the treatment of lower UTI in children < 3months and those > 3months ?

A
  • < 3months = Amox + Gent
  • > 3months = Trimethroprim or nitrofuratoin
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35
Q

What is the treatment of upper UTI’s in young children ?

A
  • 1st line = Amox + Gent
  • 2nd line = Co-amoxiclav
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36
Q

Define what nectrosing enterocolitis (NEC) is

A
  • This is an inflammatory bowel disorder in which the bowel begins to die (necrosis)
  • It can then lead to perforation of the bowel which in turn can lead to infection
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37
Q

What is the chief risk factor for NEC development ?

A

Prematurity

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38
Q

What are the signs/symptoms of NEC ?

A
  • Poor feeding
  • Vomiting +/- bile
  • Swollen & tender abdomen
  • Blood/mucus in the stool
  • May present with shock, DIC if severe
  • Usually presents in the first 2 weeks of life (& primarily in pre-terms)
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39
Q

How is NEC diagnosed?

A

Abdo X-ray shows pneumatosis intestinalis (gas within wall of the bowel) - this is pathognomic for it

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40
Q

What is the treatment of NEC?

A

Antibiotics (IV GAM) with step-down to co-amoxiclav +/- surgery

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41
Q

What are the 2 types of impetigo ?

A
  1. Bullous
  2. Non-bullous
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42
Q

What is the causative organism of impetigo ?

A

Staph.aureus

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43
Q

What age group of children does non-bullous impetigo usually affect ?

A

5-15 yr olds

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44
Q

Describe the presentation of non-bullous impetigo

A
  • Starts as tiny pustules or vesicles that evolve rapidly into honey coloured crusted plaques
  • Plaques usually on the face around the mouth & nose
  • Satellite lesions may occur as it spreads
  • May be itchy
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45
Q

What age group is more likely to be affected by bullous impetigo ?

46
Q

Describe the presentation of bullous impetigo

A
  • Lesions have a thin roof & tend to rupture spontaneously (cause still staph.A think still golden colour)
  • Usually present on the face, trunk, extremities, buttocks or perineal area
  • More likely to be painful with associated malaise
47
Q

What is the treatment of impetigo ?

A
  • 1st line = flucloxacillin
  • 2nd line = clarithromycin

If severe 1st line = clindamycin

48
Q

What is oestomyelitis and the main causative organism

A
  • It is infection of the bone marrow which may spread to the cortex & periosteum
  • Most commonly caused by Staph. A
49
Q

Describe the presentation of osteomyelitis

A
  • Acutely febrile & bacteraemic with markedly painful immobile limb
  • Swelling & extreme tenderness over affected area
  • Erythema & warmth over affected area
  • In neonates sometimes associated with septic arthritis
50
Q

How is osteomyelitis diagnosed?

A
  • Bloods - FBC & inflam markers
  • Bone culture
  • MRI
51
Q

What is the treatment of osteomyelitis >5y/o & < 5y/o?

A
  • > 5 = flucloxacillin or clindamycin
  • < 5 = Ceftriaxone
52
Q

What is the causative organism of measles ?

A

RNA paramyxovirus

53
Q

What are the signs/symptoms of measles ?

A
  • Rash on forehead & neck which spreads to the trunk & limbs
  • Cough
  • Coryza (inflam of membrane in nose)
  • Conjunctivitis
  • Koplik spots = appear on bucal mucosa, small red spots with blueish white centre (pathognomic)
54
Q

How is measles diagnosed?

A

Saliva swab for measles specific IgM & IgG

55
Q

What is the treatment of measles ?

A

Symptomatic

56
Q

What are the signs/symptoms of mumps ?

A
  • fever
  • malaise, muscular pain
  • parotitis (‘earache’, ‘pain on eating’): unilateral initially then becomes bilateral in 70% (parotid gland swelling)
57
Q

How is mumps diagnosed ?

A

Clinically usually, but can do salivary swab for specific IgM & IgG

58
Q

What is the treatment of mumps ?

A

Supportive

59
Q

What is the causative organism of rubella ?

60
Q

Descrieb the typical presentation of rubella

A
  • prodrome, e.g. low-grade fever
  • rash: maculopapular, initially on the face before spreading to the whole body, usually fades by the 3-5 day
  • lymphadenopathy: suboccipital and postauricular
61
Q

How is rubella diagnosed ?

A

Serological &/or PCR

62
Q

What is congenital CMV infection ?

A

This is when infection with CMV passes from mother to baby

63
Q

Does congenital CMV infection typically cause any problems ?

A

No - but in 10% of babies infection this will cause symptoms

64
Q

Describe the presentation of symptomatic congenital CMV infection

A
  • Jaundice
  • Pneumonia
  • Rash - small purplish spots
  • Enlarged liver & spleen
  • LBW (small head & body)
  • Seizures
65
Q

What will the majority of kids with symptomatic congenital CMV infection develop ?

A

Upto 90% will develop one or more disabilities such as:

  • Hearing loss
  • Visual impairment
  • Blindness
  • Learning difficulties
66
Q

What is the other name given to erythema infectiosum ?

A

Slapped cheek disease

67
Q

What is the causative organism of slapped cheek disease ?

A

Parovirus B19

68
Q

Describe the presentation of slapped cheek disease

A
  1. Initially causes mild symptoms such as - headache, rhinitis, sore throat, low grade fever & malaise +/- N&V
  2. After 7-10 days symptoms clear and classic slapped cheek rash appears (erythema on cheeks, sparing the nose, perioral & periorbital regions)
  3. The rash may then spread to the extremities but rarley affects the palms or soles
69
Q

If slapped cheek is untreated during pregnancy & passed onto the baby what may it develop ?

A

Hydros fetalis, hepatis, severe anaemia, inflam of the heart muscle & cardiac muscle

70
Q

When should you think of herpes simplex encephalitis in a child ?

A
  • Think of it in any child with focal or general seizures & CNS signs (esp temporal) +/- decreased conciousness
  • CNS signs may be mild or gross e.g. hemiparesis
71
Q

What investigations should be done for suspected herpes simplex encephalitis ?

A
  • CSF: lymphocytosis, elevated protein
  • PCR for HSV
  • CT: medial temporal and inferior frontal changes (e.g. petechial haemorrhages) - normal in one-third of patients
  • MRI is better
  • EEG pattern: lateralised periodic discharges at 2 Hz
72
Q

What is the treatment of HSV encephalitis?

A

IV aciclovir

73
Q

What is the causative organism of chickenpox & shingles ?

A

Varicella zoster virus

74
Q

Describe the presentation of chickenpox

A
  • fever initially - systemic upset is usually mild
  • Itchy, rash starting on head/trunk before spreading. Initially macular then papular then vesicular ==> ulcers ==> crusting
75
Q

What is the treatment of chickenpox and what should specifically be avoided ?

A
  • Tx = supportive
  • Avoid ibuprofen
76
Q

Describe the presentation of shingles

A
  • It is an acute, unilateral painful blistering rash. It affects dermatomes
  • Occasionally, two or three nerves next to each other are affected.
  • Very rarely, shingles can affect both sides of the body, but this is usually in people with a weakened immune system.
77
Q

What is the tx of shingles ?

A

Aciclovir - reduces rates of post-herpetic neuralgia

78
Q

List the symptoms which would make you consider HIV in a child/neonate

A
  • Lymphadenopathy
  • Hepatosplenomegaly
  • Persistent diarrhoea
  • Parotid enlargement
  • Shingles
  • Decreased platelets
  • Recurrent slow to clear infections
  • Failure to thrive
  • Clubbing
  • Unexplained organ disease
  • CMV, toxoplasmosis infections etc
79
Q

What are the 3 main differentials of a newborn presenting with cyanosis ?

A
  1. Cardiac disease
  2. Respiratory disease
  3. Persistent pulmonary hypertension of the newborn (PPHN)
80
Q

How do newborns with cardiac disease, resp disease & PPHN typically present differently from eachother ?

A
  • Cardiac babies tend to be blue with little or no respiratory distress. May have pre-post ductal differential
  • Respiratory causes usually associated with increased work of breathing, xray changes
  • PPHN often seen in otherwise very unwell babies. Large pre-post ductal differential.
81
Q

What is the initial treatment of a newborn presenting with collapse at the time of duct closure (2-7days postnatally) ?

A
  • ABC – support airway and breathing as necessary
  • Prostaglandin E2 to open duct
  • Multisystem supportive treatment
  • Transfer to cardiac surgical centre for definitive management
82
Q

What are the 4 main congenital heart diseases a neonate may be born with ?

A
  1. Tetralogy of fallot
  2. Transposition of the great arteries
  3. Coartication of the aorta
  4. TAPVD (total anomalous pulmonary venous drainage)
83
Q

Describe what tetralogy of fallot is

A

This consists of four defects:

  1. Pulmonary stenosis
  2. VSD
  3. Over-riding aorta
  4. R-ventricular hypertrophy

The VSD allows some deoxygenated blood into the aortas (due to the VSD being beside the opening to the aorta)

84
Q

What are the signs/symptoms of tetraolgy of fallot

A
  • Cyanosis
  • SOB & tachypnoea esp on exertion
  • Loss of conciousness
  • Clubbing of fingers & toes
  • LBW & failure to thrive
  • Harsh loud pan systolic murmur +/- thrills
85
Q

Describe what transposition of the great arteries is

A

This is where the aorta & pulmonary artery are swapped places resulting in deoxygenated blood circulating round the body which is fatal

86
Q

What are the signs/symptoms of transposition of the great arteries ?

A
  • Cyanosis in the first day of life - often within the first few hours
  • Tachypnoea
  • Laboured breathing
  • Increased HR
  • Cold, clamy skin
87
Q

Describe what coartication of the aorta is

A

This is a congenital condition whereby the aorta is narrowed

88
Q

Describe the presentation of coartication of the aorta

A
  • Usually presents in the first 3weeks of life
  • Poor feeding & lethargy
  • Tachypnoea or cardiac failure & shock
  • BP higher in the upper limbs (R-arm) and lower in the lower limbs
  • Radio-femoral delay
  • Weak femoral pulse
  • Upper body appears pink (well-perfused), lower body appears cyanotic
  • Mid-systolic murmur in the L infraclavicular area
89
Q

Describe what TAPVD is

A
  • This is a defect where oxygen rich blood does not return from the lungs to the L atrium
  • Instead O2 rich blood returns to the R side of the heart mixing with deoxygenated blood causing the baby to get less O2 than is needed.
90
Q

Describe the presentation of hypoplastic heart

A

The newborn may not have trouble for the first few days whilst the ductus arteriosus & foramen ovalae stay patent but once these close they quickly develop symptoms:

  • Tachypnoea
  • Pounding heart
  • Weak pulse
  • Cyanosis
  • Non-specific systolic murmur
  • Cardiogenic shock symptoms
  • S2 Soft & loud
91
Q

Describe what a tracheo-oesophageal fistula is

A

This is an abnormal connection (fistula) between the oesophagus & trachea

92
Q

What are the signs/symptoms of a tracheo-oesophageal fistula ?

A

Usually occur very soon after birth:

  • Frothy white bubbles in the mouth
  • Coughing or chocking when feeding
  • Vomiting
  • Cyanosis esp when baby is feeding
  • Difficulty breathing
  • Very round, full abdomen (probs air)
93
Q

What is a congenital diaphragmatic hernia ?

A
  • This is a defect in the diaphragm allowing herniation of abdominal contents into the chest.
  • Leading to impaired lung development (pulmonary hypoplasia & pulmonary HTN)
94
Q

What are the signs/symptoms of a diaphragmatic hernia ?

A
  • Difficult resucitation at birth
  • Resp distress
  • Bowel sounds in one side of the thorax (usually left)
  • pH < 7.3 & cyanosis (due to lung hypoplasia)
95
Q

What is potters syndrome ?

A

This is a condition with a typical appearance & associated pulmonary hypoplasia of a neonate and is a direct result of oligohydramnios & compression in utero

96
Q

List some of the other congenital conditions covered in other lectures

A
  • Spina bifida
  • Mytonic dystrophy
  • Microencepahly = head circumference is smaller than normal and may be assoicated with genetic abnormalities or by drugs, alcohol, viruses & toxins
97
Q

What are the signs of shock in neonates ?

A
  • Increased pulse
  • Decreaed BP
  • Decreased urine output
  • Decreased conciousness
98
Q

What is the management of shock in neonates ?

A
  • ABC +/- ventilation (fluids etc included as norm)
  • Ionotropes for BP - dopamine 1st
  • Na bicarbonate if pH < 7.2
99
Q

Which is more common cardiac arrest or cardiopulmonary arrest in children ?

A

Cardiopulmonary arrest

100
Q

Describe what hypoplastic heart is

A
  • This is a congenital condition where the L side of the heart does not form correctly e.g.
  • L ventricle underdeveloped & too small, mitral valves not formed or very small, aortic valve not formed or very small, ascending aorta underdeveloped or too small.
  • Often have a ASD
  • Due to the poor function of the L side of the heart the O2 rich blood bypasses that side by going through the patent ductus arteriosus & foramen ovalae (until they close)
101
Q

What is a ventricular septal defect ?

A

A hole which connects the ventricles

102
Q

What are the causes of VSD’s ?

A

Congenital or aquired (post-MI)

103
Q

What are conditions are congenital VSD’s associated with ?

A

Associated with chromosomal disorders (e.g. Down’s syndrome, Edward’s syndrome, Patau syndrome)

104
Q

How do VSD’s typically present?

A

May present in infancy with severe heart failure or remain asymptomatic & detected incidentally later in life

105
Q

What are the clinical signs of a VSD?

A

Classically a pan-systolic murmur which is louder in smaller defects. Heard at the left sternal edge

106
Q

What are the potential complications of a VSD?

A
  • aortic regurgitation
  • infective endocarditis
  • Eisenmenger’s complex
  • right heart failure
  • pulmonary hypertension: pregnancy is contraindicated in women with pulmonary hypertension as it carries a 30-50% risk of mortality
107
Q

What is an atrial septal defect (ASD)?

A

It is a hole which connects the atria

108
Q

What are the clinical features of an ASD?

A
  • Pulmonary ejection systolic murmur
  • Fixed splitting of S2
  • Embolism may pass from venous system to left side of heart causing a stroke
109
Q

What is the treatment of ASD’s and why ?

A
  • Treatment is surigcal closure in children before age 10
  • OR Transcatheter closure in adults if symptomatic

This is because they carry a significant mortality, with 50% of patients being dead at 50 years.

110
Q

More than 50% of VSD cases spontaneously resolve - T or F?

111
Q

What is the management of cardiopulmonary arrest in children & infants ?

A
  • 5 rescue breaths first
  • then 15:2 for C:V ratio
  • Rate should be 100-120 BPM and a Depth of 4cm for infants & 5cm for children for compressions
  • No > 10secs in assessing signs of life & deciding whether or not to start CPR
  • Secure airway in a neutral position for infants < 1year
112
Q

What is hydrops fetalis and its causes?

A
  • This is serious congenital condition defined as abnormal fluid accumulation in ≥ 2 fetal compartments of which may include ascities, pleural effusion, pericardial effusion, skin oedema
  • Causes include immune (Rh disease & ABO incompatability) and non-immune - cardiac, chromosomal etc

Y4 Neonatology (10 decks)

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