The Sick newborn

Question 1

Clinical Assessment?

Answer 1

Respiratory rate: 40 – 60 / minute
Work of breathing / respiratory effort
HR: 120 - 140 / minute
Cap refill 2 - 3 seconds
Colour – pink/blue/white
SaO2 95% or above
BP ?
Others – jaundice, low tone (floppy), seizures, poor feeding, bilious vomit

Question 2

Initial Management?

Answer 2

Temperature control (crucial as baby gets hypoglyceamic if gets cold)
Airway and breathing
Airway support +/- oxygen
Circulation
Fluids
Inotropic drugs
Metabolic homeostasis
Glucose management
Acid-base balance - is correction required
Antibiotics

Question 3

Ongoing Management?

Answer 3

• Diagnostic work-up
• Further support
  
  • Ventilation
  • Drugs
  • Specific therapy e.g. therapeutic cooling
  • Surgery
  • Transfer
• Care of family

Question 4

How does sepsis present?

Answer 4

Non-specific
Quiet
Poor feeding
Floppy
Tachypnoea
Apnoea
Tachycardia
Bradycardia
Temperature instability –high or low (baby tends to be cold when they have sepsis)

Question 5

Sites of infection?

Answer 5

Blood stream - bacteraemia (Bac in the blood stream) /septicaemia (When bacteraemia gets abnormal and gets high)
CNS - meningitis
Respiratory - pneumonia
Gastrointestinal – Necrotising Entero Colitis
Urinary – UTI

Others:
Skin
Bone

Question 6

Bacterial Infections?

Answer 6

Group B Streptococcus
E. Coli
Staphylococcus aureus

Question 7

Antibiotic Choice?

Answer 7

Benzylpenicillin – Gram positive cover – bactericidal
Gentamicin – broad Gram negative cover – bactericidal

Question 8

Viral infections?

Answer 8

Cytomegalovirus

Question 9

The term TORCH screen?

Answer 9

Toxoplasma, Others (syphillis, HepB), Rubella, CMV and Herpes

Question 10

Syphilis?

Answer 10

• Highest risk when woman has early stage syphilis (infection within last 2 years)
• Treatment 30 days prior to delivery for reducing congenital infection

Question 11

What are the Pregnancy/Birth Related Pathologies?

Answer 11

Respiratory – Transient Tachypnoea of Newborn/Pneumothorax/Meconium aspiration/Respiratory Distress Syndrome
Birth Asphyxia- lack of oxygen and blood flow to the brain
Circulatory- Persistent Pulmonary Hypertension/Foetal anaemia

Question 12

Clinical signs of respiratory distress?

Answer 12

Tachypnoea
Recession
Grunting
Blue, low saturations

Question 13

Transient Tachypnoea of the Newborn (TTN)?

Answer 13

• the most common cause of Tachypnoea
• Most common in term infants delivered by Caesarean section
• Due to delay in clearing lung fluid (fluid in the lungs does not clear away)
• Lung fluid usually clears into interstitium and then to lymphatic system
• Dependant on active **epithelial Na channels **– activated by adrenaline
• CXR shows fluid in the horizontal fissure

*Fluid goes into interstitm and then blood stream with first gasp of the air. The Na channel doesn’t shot down and more fluid produces after birth

Question 14

Pneumothorax

Answer 14

• spontaneously
• Due to meconium/ infection/resuscitation/surfactant deficiency
• Conservative management vs chest drain insertion

Question 15

Respiratory distress syndrome?

Answer 15

• Surfactant deficiency can occur in term infants
• Much more common in preterm infants
• Associated with
  -IUGR (not growth enough in the womb),
  -Maternal diabetes
  -infection
  -birth asphyxia (lack of O2 and blood to the brain)
  -Meconium aspiration
• CXR – Ground glass appearance
• Mx- is with respiratory support and surfactant replacement

Question 16

Meconium Aspiration Syndrome (MAS)?

Answer 16

• When the baby pass the stools in the womb and amniotic and breathes it in during distress delivery, (fetal distress sign).
• Common (up to 20% of term deliveries, rare in preterm)
• Meconium can cause airway obstruction, inflammation, surfactant dysfunction
• MAS in severe form linked with asphyxia and persistent pulmonary hypertension

Question 17

Hydrops Fetalis is one of the causes of baby’s heart failure. what is it??

Answer 17

• Hydrops fetalis is severe swelling (edema) from too much fluid leaves the baby’s bloodstream and goes into the tissues like liver
  As a result of
• rhesus disease
• chromosomal

Question 18

What is the another heart failure cause aprat from hydrops fetalis?

Answer 18

Failure to adapt to postnatal life - persistent pulmonary hypertension of the newborn (PPHN)

Question 19

Cardiac Presentations?

Answer 19

• Tachypnoea ; but may not have much in the way of signs of respiratory distress
• Cyanosis - usually not responsive to oxygen
• Murmur
• Femoral pulses maybe weak or absent
• Circulatory collapse

Question 20

Critical Congenital Cardiac diseases?

Answer 20

• Tetralogy of Fallot
• Transposition of great arteries
• Coarctation of the aorta (a part of the aorta is narrower than usual)
• TAPVD-Total Anomalous Pulmonary Venous Drainage is where “the four pulmonary veins do not drain into the left atrium but instead drain via unique pathways into the right atrium or systemic veins”
• Hypoplastic heart (incomplete LV)

Question 21

Give a disease example for each of the following:
Neurological
Renal
Muscular

Answer 21

Neurological: Microcephaly, Spina bifida

Renal: Potters syndrome

Muscular: Myotonic dystrophy

Question 22

Why baby can have hypoglycaemia and Acidosis?

Answer 22

• Hypoglycaemia
  
  • Reduced to ‘reserves’ - LBW/SGA (Low Birth Weight/ Small at Gestational Age)
  • Related to maternal disease - IDM (Infant of a Diabetic Mother)
  • Evidence of more complex metabolic disorder
• Acidosis - inborn error of metabolism