The Preterm Baby: RDS & NEC Flashcards
Describe what is meant by prematurity and extreme prematurity [2]
How long do you continue accounting for corrected gestation for? [1]
Prematurity: < 37 weeks, extreme prematurity: < 28 weeks gestatiom
Corrected gestation is accounted for the first 2 years of life
- but is not relevant for immunisations
Name some risk factors that impact prognosis of a pre-term baby [5]
- Maternal health / infection
- Female babies do better
- Est. foetal weight
- Multiple pregnancies worse than singleton
- Antenatal steroids / MgS
- Location of delivery
Which maternal intervention is likely to have the biggest impact? [1]
Corticosteroids
The majority of babies born at 26 weeks will die
True
False
False
Describe the perinatal optimisation care pathway with regards to the antenatal period [3]
Antenatally:
Prediction of pre-term birth
Fetal fibronectin:
- protein that helps the amniotic sac attach to the uterine lining during pregnancy. A fetal fibronectin test measures the amount of fFN in vaginal fluid to assess the risk of preterm birth.
Cervical length
- in singleton pregnancies a cervical length of < 25mm at < 23weeks + 6 days is associated with an increased risk of preterm birth
Describe the perinatal optimisation care pathway with regards to the perinatal period [4]
Place of birth:
- Level 3 units have better outcomes than level 2 /1. Better to transfer in-utero
Antenatal steroids
- Reduce risk of intraventricular haemorrhage
- Reduce risk of resp distress syndrome
MgS
- Reduces risk of cerebral palsy
Abx:
- Reduces poor outcomes
Birth of a pre-term baby is imminent - what equipment do you need to have? [4]
Resuscitaire, pre warmed
Airway equipment
Normothermia equipment
Surfactant
What is optimal cord management? [1]
What does it reduce the risk of? [2]
Delaying cord clamping for up to 60 seconds
- reduces mortality and risk of needing blood transfusion and inotropes
How can you maintain baby temperature? [5]
Optimal room temp
External heat sources
Transwarmer bag
Hat
Plastic bag - keeps heat in
From Ward Poster
Describe the perinatanl pre-term optimisation plan [9]
Place of birth:
- All babies < 27 weeks or EFW < 800 g should be born in a NICU
MgS:
- Women giviing birth < 30 weeks should receive a loading dose and ideally a 4hr transfusion in the 24hrs before birth
Optimal cord management:
- umbilical cord clamped at or after one minute of birth
Breast milk:
- All babies should receive mother’s milk within 24hrs and ideally within 6
Caffeine:
- Give to babies < 30 weeks within 24hrs
Antenatal steroids:
- < 34 weeks, try and give a full course at least 7 days prior to birth
Prophylactic Abx:
- Give during labour
Thermal care:
- Take temp within one hour and should be between 36.5 and 37.5
Resp management:
- When conventional ventilation is appropriate, volume targeted ventilation should be used as initial mode of ventilation to avoid lung injury
Golden Hour: admission ot the neonatal unit:
- What should you do / control? [5
- Which medications should be given [6]
Resp. management
Access/Fluids
Early colostrum
- encourage mum so can give ASAP
Temp control and incubator humidity
Monitoring, NG and admission swabs
Medications:
* Caffeine
* Vit K
* Abx
* Hydrocortisone
* Prophylactic fluconazole
* Probiotics
Chest x-rays and USs
What is the benefit of giving caffeine to neonates? [2]
Stimulant so reduces the risk of apneas.
Can also cause improved neurodevelopment outcomes
What is the role of surfactant? [1]
Pulmonary surfactant is a complex mixture of phospholipids and proteins that functions to reduce surface tension at the alveolar air interface preventing atelectasis
Describe a risk of giving ventilation in neonates [1]
Too much ventilation:
- Blow off CO2: impacts cerebral circulation and increase risks of brain injury
Describe what a CXR of RDS looks like [2]
Ground glass shadowing with air bronchograms
AKA hyaline membrane disease
Name 4 risk factors for respiratory distress syndrome [4]
- male sex
- diabetic mothers
- Caesarean section
- second born of premature twins
How do you manage RDS? [4]
Management
* prevention during pregnancy: maternal corticosteroids to induce fetal lung maturation
* oxygen
* assisted ventilation
* exogenous surfactant given via endotracheal tube
Describe some respiratory diseases of neonates [2]
Bronchopulmonary dysplasia:
- Preterm from of chronic lung disease. Due to maldevelopment of lungs postnatally
Pulmonary interstitial emphysema:
- severe form of BPD where air enters the interstitial spaces
Chronic lung disease of prematurity:
- Typically pre-term infants w/ ongoing oxygen requirement at 36+0 cGA
How can you predict mean BP from a babys gestation? [1]
Mean BP matches their gestation
What are typical calories needs per day for a baby? [1]
120-150 ml/kg per day
What is the most likely cause of the baby’s condition? [1]
Necrotising Enterocolitis
Which investigating is most appropriate to dx necrotising enterocolitis?
Blood gas
CT abdomen
CRP
X-ray abdomen
X-ray abdomen
Describe the pathophysiology of NEC [1]
What are the differences in neonate intestines that make them at an increased risk? [5]
The pathophysiology of NEC is not fully understood. But perhaps the most significant contributing factor in the development of NEC is intestinal immaturity. The characteristic differences in neonatal intestines compromise multiple gastrointestinal protective factors:
* Reduced gastric acid production
* Reduced intestinal barrier
* Immature immune function
* Immature digestion
* Immature motility
This intestinal immaturity is compounded by abnormal intestinal microbiota due to the frequent use of antibiotics in neonatal care. This culminates in an excessive inflammatory response leading to tissue injury and intestinal necrosis.
Describe the presentation of NEC:
- symptoms [5]
- signs / exam findings [5]
Premature baby:
- developing feeding intolerance
- vomiting
- lethargy
- abdominal distension
- progresses into bloody stools at around 9 days of age.
Signs:
* Shiny distended abdomen
* Periumbilical erythema
* Abdominal tenderness
* Bilious gastric aspirate
* Shock
What are the different stages of Bells staging criteria for NEC with regards to signs [3]
Stage 1: Suspected NEC
* Lethargy
* apnoea
* temperature instability
* abdominal distention
* vomiting
* heme-positive stool
Stage II: Proven NEC
- Similar to stage I with abdominal tenderness, abdominal wall discolouration, abdominal mass, mild metabolic acidosis
Stage III: Advanced NEC:
- Critically ill neonate with hypotension
- bradycardia
- peritonitis
- respiratory and metabolic acidosis,
- disseminated intravascular coagulation
What are the different stages of Bells staging criteria for NEC with regards to radiological signs [3]
Stage 1: Suspected NEC
- Intestinal dilation / normal
Stage II: Proven NEC
- Intestinal dilation
- ileus
- ascites
- pneumatosis intestinalis
Stage III: Advanced NEC:
- Pneumoperitoneum
Describe how you investigate for NEC [3]
Abdominal radiography is central to NEC diagnosis. Radiological findings which are pathognomic of NEC include:
* Pneumatosis intestinalis (seen as gas in the bowel wall on x-ray - mottled / soap bubble appearance
* Portal vein gas
Other radiographical signs which can support a diagnosis of NEC include:
* Dilated bowel loops
* Absence of bowel gas
* Persisting gas-filled bowel loops
* Pneumoperitoneum can be seen in advance NEC - Riglers sign
* (American) Football sign
Bloods:
- A rapid decrease in neutrophil count, platelet count or white cell count or persistently high C-reactive protein can indicate disease progression.
What does this x-ray show in NEC? [1]
Portal venous gas
What is the name for this sign? [1]
Air eccentuating the falciform ligament
How would you distinguish NEC from intestinal perforation of the newborn? [3]
Differences:
* Abscence of pneumatosis intestinalis on abdominal xray
* Blue discolouration of abdominal wall
* Occurs in first week of life
How would you differentiate NEC from infection enteritis? [1]
The characteristic radiological findings of NEC are not present in infection enteritis
How do you manage NEC? [4]
Neonatal emergency:
* Abdominal decompression via nasogastric tube insertion
* Bowel rest via total parenteral nutrition
* Broad-spectrum intravenous antibiotics- - Generally consisting of a penicillin, gentamicin and metronidazole
* Surgical management options (if perforation is suspected or the infant is deteriorating): Peritoneal drain; Laparotomy with resection of necrotised bowel and enterostomy with stoma creation
