W08 - PAEDS: Neonatology; Common Postnatal Issues & NNU Flashcards
Growth Related Problems in Utero
<2500g born too small
- small for gestational age
- intra-uterine growth restriction
- hypotrophy
- symmetric & asymmetric hypotrophy
<1500g = very low b/w
<1000g = extremely low b/w
<37w = preterm
<28w = extremely preterm
Reasons and Outcomes of being born small
Maternal:
- maternal pre-eclamptic toxemia => small for dates
Foetal:
- chromosmal: edward’s syndrome
- infection: CMV
- placental
- twin pregn.
- USS OF BRAIN BY END OF 1ST W.
- deterioration cognitive and behavioural between 2yo and 6yo
Learn about common problems of prematurity
- perinatal hypoxia
- hypos. glyc., therm.
- polycythaemia
- thrombocytoponeia
- GI problems: feeds
LT:
- HT, reduced growth, obesity, ischemic heart disease
Respiratory Preterm Complications
1) RDS
> antenatal steroids
surfactant = wean off
> early. extubation
non-invasive support = N-CPAP
minimal ventilation
2) Bronchopulmonary dysplasia
> patience; nutrition & growth
> steroids
3) Apnoea / irreg. breathing / desats
> caffeine
> n-cpap
Neurological Preterm Complications
1) IVH = Intraventricular Hemorrhage in Premature Infants
* common limiting factor for good prognosis
gradeIV = 75% adverse outcome, intraparenchymal extension
> AN steroids
drainage
2) PVL = Periventricular leukomalacia
- cerebral palsy, 1-2yo presentation
> supportive, physio
3) posthemorrhagic hydrocephalus from prematurity
CVS Preterm Complication
1) PDA = LtoR shunt
- over-perfusion of lungs, lung edema. + systemic ischemia
=> retention and low renal perfusion, GI ischemia
acyanotic defect
> IE risk reduction
Cardiac catheterisation
NSAID = closure
GI Preterm Complication
1) Necrotising entero-colitis
ischemic, inflamm., necrosis of bowel
> abx and parenteral nutrition
>sx
2) NUTRITION
- patients triple in size during hospital stay with enormous nutritional input
CVS Development
- development at the end of 3rd w
- heart starts to beat at the beginning of the 4w
- critical period of heart development is 20 to 50
- ductus venosus =oxygenated blood
- LV Ao = blood via the foramen ovale
- pulm. artery - PDA
- saturations in foetal body 60-70%
Normal vital signs of Full Term newborn
BP 70/44 - first hour
BP 70/42 - 1st d
BP 77/49 - 3rd day
Role of thermoregulation
- Maternal in womb
- Newborns lack shivering thermogenesis = metaabolic prod of heat
- Brown fat innerv. sympathetic neurons
- Cold stress = lipolysis and heat production
Assessing newborn breathing
Non invasive:
Blood gas determination
PaCO2 5-6 kPa, PaO2 8-12 kPa
Trans-cutaneous pCO2/O2 measurement
Invasive:
Capnography
Tidal volume 4-6 ml/kg
Minute ventilation:
Tidal Volume ml/kg x respiratory rate
Flow-volume loop.
Physiological Jaundice
Present from day2/3 will resolve
- risk of irreversible KERNICTERUS
> blue light therapy
exchange transfusion
Fluid Loss in premature infants
- Increased Insensible Water Loss (IWL)
Via immature skin and breathing
Physiological IWL is 20-40 ml/kg/day but could be up to 82 ml/kg/day in 750-1000 g - Increased loss through kidney:
- slower GFR
- reduced Na reabs.
- decreased ability to concentrate or dilute urine
Physiological anemia of newborn
By week 10, dropin Hb
* stimulate increased prod of EPO
- may have reduced erythporesis dt premarutiy
- infection
- blood letting
Causes of neonatal jaundice and mgmt
1) 24hr
- hemolytic dt rh incompatibility, ab, hereditary anemias
2) 2nd day to 3rdw
- physiological
- dehydration
- breast milk
- sepsis
- polycythemia
- bruising
- hemolytic
- crigler najjar syndrome
3) Prolonged jaundice: 2w+
- breastmilk
> hydrate
phototherapy
exchange transfusion
immunoglobulin
Postnatal Skin Presentations
1) ERYTHEMA TOXICUM
- maculo-papular rash
- 30-70% of normal term
* self-resolves, no Rx.
2) MONGOLIAN BLUE SPOTS
* pigmentations: lower-back and buttocks
3) STORK MARKS / NAEVUS SIMPLEX: cap. vascular malformations
* back of neck or midline of face
* fades
4) PORT WINE STAIN / NAEVUS FLAMMEUS
flat or slightly raised, do not regress.
5) STRAWBERRY NAEVUS
*cluster of dilated capillaries
Common Postnatal Issues
1) HYPOTHERMIA
> resus. and cold stress
2) HYPOGLC.
* jitters, temp instab.,lethargy, hypotonia, apnoea, poor feeding, vom., high pitched/weak cry, seizures
3) BILOUS VOMITING
4) RESP DISTRESS.
- grunting, retracts, nasal flaring = red flags for. resp distress
* sepsis
* TTN
* meconium aspiration
5) ABSENT FEMORAL PULSES = COARCTATION of AO
6) CLEFT LIP
* adjustment for feeding
* airway problems
+hearing screen, cardiac ECHO, trisomies
7) ABSENT RED REFLEX (EYES): lens opacification or retinoblastoma
Spinal Dimples
dimples commonly found during newborn examination
* SPINA BIFIDA
+ hairy tuft
*SPINAL IMAGING
Blood in nappy
normal
1) pseudomenstruation: from vagina d2-10
*drop off of oestrogen from birth
2). URATE CRYSTALS: behind on fluids
CEPHALOHAEMATOMA
local. swelling of head, soft non-transluscent
* limits parietal bone
* haemorrage beneath pericranium
±hemolysis = neonatal jaundice
> SELF-RESOLVE 3-4w.
TALIPES
medial varus
lateral. valgus
= deviation of foot
> physio
fixed manipulation, strapping, casting, or possible sx.
DDH
- barlow test, ortolani test
> relocate head offemur to acetabulum to ensure normal development
pavlik harness
sx reduction
Trisomy 21
*dysmorphism
* hypotonia
*cardiac defects = ECHO screening
* thryoid = annual check
* haematological
* learning difficulties
Mgmt of Sepsis in Neonate/Postnatal for Admission
Partial septic screen (FBC, CRP, blood cultures) and blood gas
Consider CXR, LP
IV penicillin and gentamicin 1st line
2nd line IV vancomycin and gentamicin
+ Add metronidazole if surgical/abdominal concerns
Fluid management and treat acidosis
Monitor vital signs and support respiratory and cardiovascular systems as required
Commonest cause of neonatal sepsis
group b strep
e. coli
listeria
coag. neg staph
h. influenza
Congenital Infection
TORCH
- toxoplasmosis
- other
- rubella
- CMV
- Herpes simplex virus
=> IUGR, brain calcifications, neurodevelopmental delay, visual impairment, recurrent infections
- Maternal risk factors include lapsed immunizations, sexually transmitted infections, and animal exposures during pregnancy.
TTN
transient tachypnoea of newborn
- self limiting, 1st few hours of life
- grunting, tachy.opnea, o2 req.
- delay in clearance of fetal lung fluids
> supportive
abx
fluids
O2 support, airway support
Cardiac Causes for Admission to NNU
- cyanotic baby
+ sepsis - ?non-innocent humour
1) truncus art.
2) TGA
3) tricuspid atresia
4) ToFallot
5) TAPVD
Admission of hypoglc. and mgmt in NNU
> IV glc.
central IV access
> fluids
glucagon
hydrocortisone
Hypothermia mgmt in NNU
> place in incubator
> sepsis screen + abx
> thryoid funct?
> monitor blood glc.
Approach to Birth Asphyxia
> Therapeutic hypothermia via cooling
> Treat seizures
> Fluid restriction to prevent oedema (encephalopathy)
- risk of Hypoxic Ischaemic encephalopathy
Failure to. pass stool
- meconium-caused
- plug
- meconium ileus = ?CF
- large bowel atresia
- imperforate anys ±fistula
Neonatal Abstinence Syndrome
Withdrawal from physically addictive substances taken by the mother in pregnancy
- finnegans score
- urine toxicology
> comfort
morphine
phenobarbitone
