Week 5 - D - The sick term infant - Infection, Pregnancy/birth complications, Congenital Anomalies, Metabolic diseases

Question 1

How long does the neonatal period last? How long does the puerperal period last?

Answer 1

The neonatal period lasts 4 weeks - the first 28 days of life

The peuperal period lasts approx 6 weeks - this is the time it takes for the mothers body, including hormones and uterus levels - to return completely to their non-pregnant state

Question 2

What is the most common cause of death in children under 5 years in the neonatal period?

Answer 2

This would be prematurity The neonatal period is the transitional time from intrauterine to independent existence

Question 3

A neonate might become unwell at delivery, first few hours of life or days, or up to 28 days post delivery What is the scoring system used to quickly summarise the health of the newborn? When is it carried out?

Answer 3

This is the Apgar Score It is assessed at 1 minute and 5 minute post delivery

Question 4

What are the 5 different sections assessed when using the apgar scoring system?

Answer 4

Appearance - colour Pulse Grimace - reflex irritability (cough/cry) Activity - muscle tone Respiration (breathing / crying)

Question 5

When the baby is born, a newborn clinical assessment is carried out Inspect tone (activity), level of arousal (grimace), colour (appearance) and vital signs (heart rate and respiration) - basically APGAR What is the normal resp rate and heart rate of the newborn?

Answer 5

Normal resp rate of a newborn is 40-60 breaths per minute Normal heart rate of newborn is 120-160 bpm

Question 6

In the intial management of the sick term infant, it is important to assess the infants temperature, ensure the infant has proper airway control and ventilate if required, also assess the infants circulation and give fluid if required What do you have to be careful of when giving fluids to the infant?

Answer 6

Do not want to cause central pontine myelinosis

Question 7

WHat is the chest compression to ventilation rate in a neonatal resuscitation? Should the neonate be commenced on 100% oxygen initially?

Answer 7

Resuscitation of term infants should commence in air.

The recommended compression: ventilation ratio for CPR remains at 3:1 for newborn resuscitation.

Use 21-30% oxygen concentration initially in preterm infants

Question 8

If the child happens to go into arrest - it is important to be aware of how to carry out the CPR Is arrest in infants more commonly due to respiratory or cardiac arrest? What is the difference when opening the infnt and adult airway?

Answer 8

Respiratory arrest is more common in infants

Cardiac arrest is more common in adults

• When opening the adult airway - it is important to tilt the head/chin
• In infants the airway is open when the head is in neutral so no need to tilt

Question 9

After ensuring the airway is patent, what is the difference between adults and infant for listening feeling for breathing for 10 seconds and chcecking for signs of life ie carotid pulse?

Answer 9

• Adults
  
  • * Ensure airway is patent - head/chin tilt
  • * The look and feel for signs of breathing/signs of life (carotid pulse) for 10 seconds
  • * Then proceed to carry out chest compressions
• Infant
  
  • * Ensure airway is patent - head in neutral
  • * Look and feel for signs of breathing for 10 seconds
  • * Deliver 5 rescue breaths
  • * Look & feel for signs of life 10secs- cough/gagging

Question 10

Infants After looking for signs of life - start chest compression What is the rate of rescue breaths to chest compressions in infants/adults? What is the depth of the compression? Is CPR in a child carried out in the same way as in an adult or infant?

Answer 10

Infant - 15 chest compressions to 2 rescue breaths - 1/3rd of the chest depth for the chest compressions

Adult - 30 chest compressions to 2 rescue breaths - 5-6cm depth for chest compression at a rate of 100-120 compressions per minute

CPR in a child is done the same way as in an adult apart from the chest compressions remain as 1/3rd of the chest

Question 11

Ongoing management of the sick term infant can include further support if necessary The sick baby is usually down to any of 4 different disturbances * Congenital anomalies * Infection * Pregnancy/birth related * Metabolic disturbances What are the three types of infectants?

Answer 11

Viral bacterial and fungal

Question 12

What are the two common types of bacterial infection within the first 48 hours of birth in the neonate?

Answer 12

Within the first 48 hours Group B strep and E.coli are the common infectants

• Group B strep - colonises mothers vagina

E-coli - bowel commensal

Question 13

What is the common causes of meninigits in a neonate?

What is the most common cause of meningitis in children? (up to 10 years of age)

Answer 13

Mneingiits in neonates - GroupB strep, Listeria monocytogenase, E.coli

• Group B strep - colonises vaginal flora
• E.coli - gut commensal
• Listeria monocytogenase - eating cheese and pate etc during pregnancy (bacteria found in these that can cross the placenta)

Question 14

Staph aureus and staph epidermis are other causes of bacterial infections in neonates What is the acronym used to sum up the viral infections that can cause congenital defects in babies?

Answer 14

TORCH T - toxoplasmosis O - others R - rubella C - cytomegalovirus H - herpes

Question 15

Sick baby Infection Pregnancy /birth related problems Congenital anomalies Metabolic disturbances What pregnancy.birth related problem can cause neonatal seiazures?

Answer 15

This could be hypoxic ischaemic encephalopathy

Question 16

What causes hypoxic ischaemic encephalopathy?

Answer 16

HIE is due to asphyxia during pregnancy/birth and results in multi - organ failure due to asphyxia

Question 17

In hypoxic ischaemic encephalopathy, the baby will have poor APGAR scores with active resuscitation often being required To prevent further damage the child can be medically monitored to: * Maintain normal blood glucose * Maintain normal blood pressure * Prevent or control seizures * Prevent or minimise cerebral oedema What can be given as 1st&2nd line for prolonged seizures?

Answer 17

For prolonged neonatal seizures give Phenobarbital as 1st line Phenytoin as 2nd line if seizures continue

Question 18

There is also respiratory related issues due to pregnancy/birth that can cause the baby to be sick (unwell) Transient tachypnoea of the newborn (TTN) - what causes this? Spontaneous and secondary pneumothorax - what can cause the secondary pneumothorax?

Answer 18

Transient tachypnoea of the newborn - due to excess lung fluid - usually resolves within 24 hours - cesarean section and premature are big risk factors

Secondary pneumothorax can often be due to active resuscitation of the newborn

Question 19

Pregnancy/birth related cardiac problems are also an issue in the neonate What is the problem known as where the foetal circulation system does not adapt due to the foramen ovale and the ductus arteriosus remaining open? Causes the foetus to be cyanotic

Answer 19

This would be persistent pulmonary hypertension of the Newborn (PPHN)

Question 20

Other pregnancy/birth releated cardiac conditions include the accumulation of fluid What is this condition in the fetus, characterized by an accumulation of fluid, or edema, in at least two fetal compartments?

Answer 20

This is hydrops foetalis

Question 21

Hydrops fetalis usually stems from fetal anemia, when the heart needs to pump a much greater volume of blood to deliver the same amount of oxygen. This anemia can have either an immune or non-immune cause. What condition is hydrops foetalis associated with? Important to correct the anaemia in this condition

Answer 21

Hydrops foetalis is associated with Rhesus disease - this is because this disease can attack the newborn red blood cells causing the foetus to become anaemic - therefore in an attempt to deliver the same amount of oxygen, the heart pumps a greater volume of blood leading to a build up of fluid

Question 22

Name some congenital cardiac malformations?

Answer 22

Tetralogy of Fallot Transposition of the great arteries Coarctation of the aorta Total Anomalous Pulmonary venous Connection (TAPVD) Ventricular septal defect / atrial septal defect

Question 23

Describe tetralogy of fallot?

Answer 23

Tetralogy of fallot - Right ventricular hypertrophy, Pulmonary stenosis, Ventricular septal defect and Overriding aorta Results in deoxygenated blood travelling around the body

Question 24

Where is a VSD best heard?

Answer 24

Harsh systolic lower left sternal edge murmur

Question 25

What treatment can be given for transposition of the great arteries until surgery is carried out?

Answer 25

Can give prostoglandins - this maintains the ductus arteriosus and therefore blood that - usually PGE1 is given (although E2 is the main prostoglandin keeping the DA patent during pregnancy)

Question 26

Congenital respiratory disease also exists What are two main respiratory congenital anomalies?

Answer 26

Tarcheo-oesophageal fistula Diaphrgmatic hernia

Question 27

A diaphragmatic hernia is a birth defect in which there is an abnormal opening in the diaphragm. The diaphragm is the muscle between the chest and abdomen that helps you breathe. The opening allows part of the organs from the belly to move into the chest cavity near the lungs WHat can a diaphragmatic henia cause?

Answer 27

Can cause lung hypoplasia, as well as persistent pulmonary hypertension of the newborn

Question 28

A tracheoesophageal fistula (TEF, or TOF; see spelling differences) is an abnormal connection (fistula) between the esophagus and the trachea. TEF is a common congenital abnormality, but when occurring late in life is usually the sequela of surgical procedures such as a laryngectomy. What are the symptoms of a TEF?

Answer 28

Frothy white bubbles appearing in the mouth

Coughing or chocking when feeding

Vomiting

Surgical repair required

Question 29

Other congenital anomalies include neural tube defects such as anencephaly, spina bifida, gastrochisis Renal anomalies such as Potter’s syndrome Muscular anomalies such as mytonic dystrophy What is potter’s syndrome caused by?

Answer 29

In Potter syndrome, the primary problem is kidney failure. The kidneys fail to develop properly as the baby is growing in the womb. he kidneys normally produce the amniotic fluid (as urine).

Question 30

What is the mnemonic to hep remember the clinical features of Potter’s syndrome? (POTTER)

Answer 30

• P - pulmonary hypoplasia (oligohydramnios - poor development of the lungs)
• O - oligohydramnios - no kidneys so no amniotic fluid produced as urine
• T - twisted skin - wrinkly
• T - twisted face - low set ears, prominent epicanthic folds
• E - extremity deformities eg clubbed hands and feet
• R-renal agenesis(bilateral)

Question 31

Sick term infant - Infection Pregnancy/birth related complications Congenital anomalies Now matabolic disease What is the usual cause of hypoglycaemia in neonates? What is the blood glucose level for hypoglycaemia?

Answer 31

BG <2.6mmol/l is hypoglycaemia Due to low glucose reserves eg SGA or low birth weight Can also be due to mother having diabetes