Week 5 - Neonatal Tutorial - Jaundice, Hypothermia, Neonatal Abstinence

Question 1

Baby Details: Baby Smith Gestation 37+2 weeks Mode of delivery: Forceps Birth weight = 2300g APGARS – 7 @ 1min , 9 @ 5min Is this baby term and is it an appropriate weight?

Answer 1

This baby is term - 37+0 weeks to 40+6 weeks- and is therefore small for gestational age as less than 2.5kg of weight in a term baby is SGA

Question 2

Maternal Details: Mrs Claire Smith , Age 32 years Hepatitis C positive Blood group A+ve, Anti Cw antibodies – rising titres in third trimester Smoker of 10/day throughout pregnancy Maternal substance abuse – currently on methadone and valium detox programme 1. What factors could have contributed to Baby Smith being small for gestational age?

Answer 2

Baby Smith is small for gestational age The baby could be constitutinally small or Due to the fact the mother is a smoker Substance misuse can also can IUGR

Question 3

Define small for gestational age?

Answer 3

Small for gestational age is when a baby weighs less than the 10th centile for their gestational age (10th centile means that the baby is in the lightest 10% of babies for its gestational age)

Question 4

What is the Anti-Cw antibodies? What may these antibodies cause?

Answer 4

Anti-Cw antibody is a low frequency immunoglobulin (IgG) against red-cell antigen Cw It is clinically significant as it may cause haemolytic disease of the newborn (HDN)

Question 5

How are the different types of hepatitis transmitted? Which hepatitis have vaccines available?

Answer 5

* Hep A - transmitted through contaminated faeces - areas of poor sanitation * Hep B - transmitted through bodily fluids - blood, semen, saliva * Hep C - mostly transmitted through blood * Hep D - infections only occur in those infected with HepB * Hep E - transmitted through water &faecal route Vaccinations - hepA, hepB, hepE but not widely available yet (2018) - still being tested for efficacy

Question 6

In the case of Mrs Smith where she is hepC positive, how should the baby be assessed to see if it has the infection from vertical transmission? What is vertical transmission?

Answer 6

Measure the hepC viral load over the 1st 18 months to assess to see if the baby has the virus Vertical transmission is mother to child transmission

Question 7

Is it safe for a mother infected with hepatitis B virus (HBV) to breastfeed her infant immediately after birth? Is it safe for a mother infected with hepatitis C virus (HCV) to breastfeed her infant? 3. Are there any contraindications to breastfeeding in this case of Ms Claire Smith?

Answer 7

Yes it is safe in both cases to start breastfeeding immediately after birth Ms Claire Smith can start breastfeeding - she i HepC positive but no evidence exists that HepC can be passes on via breastfeeding

Question 8

If a mother has hepB and gives birth to a child, what should be given to the baby within the first 12 hours of life?

Answer 8

All infants born to HBV-infected mothers should receive hepatitis B immune globulin and the first dose of hepatitis B vaccine within 12 hours of birth.

Question 9

Initial review The midwife on the postnatal ward calls as she is concerned he is not maintaining his temperature well. His temperature is 36.2˚C. 4. What is considered a normal temperature range for newborns?

Answer 9

A normal temperature range for newborns (and adults) is 36.6 degrees to 37.2 degrees Celsius Babies with infections may present with hypothermia and cold babies are a risk factor for other pathology

Question 10

5. Why are newborns particularly at risk of heat loss? How do they lose heat? (4 ways) Which two ways are more common for a baby to lose heat?

Answer 10

Babies have a large surface area and are wet due to the amniotic fluid therefore are likely to lose heat Heat can be lost via: Radiation - surrounding air being colder Conduction - loss of heat through direct contact with a colder surface Convection - loss of heat through air movement Evaporation - loss o heat when water turns to a gas Radiation and convection are the most common ways

Question 11

Initial review The midwife on the postnatal ward calls as she is concerned he is not maintaining his temperature well. His temperature is 36.2˚C. 6. What simple measures could help to improve his temperature?

Answer 11

Dry the baby - put a hat on the babies head as this is a large surface area to lose heat and advise skin to skin contact with the mother

Question 12

She calls you again to say that his blood sugar (BM) is low at 2.0 and his repeat temperature is 35.8˚C. 7. What factors put babies at risk of hypoglycaemia? What drug taken for hypertension in pregnancy can cause hypoglycaemia? Which factors are present in this babies case?

Answer 12

Risk of hypoglycaemia in baby - Maternal diabetes Hyperinsulinaemia in child Infection in child Hypothermia in child Feeding Labetalol (alpha&beta blockade can cause hypos) Factors present in this case Likely to be infection and hypothermia

Question 13

What can prolonged hypoglycaemia cause to the neonate? What is the glucose level for hypoglycaemia in babies? Why is it lower than the normal 4mmol/l gluocse

Answer 13

Prolonged hypoglycaemia can put the baby at risk for cerebral palsy Glucose level for hypoglycaemia in babies - <2.6mmol/l It is lower than the adult threshold because at birth the baby wont be getting the maternal glucose supply for energy and therefore glucose levels drop in addition for the baby utilising the glucose stores as fuel for brain and organs - however if it dips past 2.6 - hypoglycaemia

Question 14

She calls you again to say that his blood sugar (BM) is low at 2.0 and his repeat temperature is 35.8˚C. 8. What signs of hypoglycaemia may be seen in this baby?

Answer 14

Baby may be lethargic, floppy, jitteriness and can persist to seizures

Question 15

What are risk factors for neonatal hypoglycaemia again?

Answer 15

Risk factors: Preterm baby - <37 weeks gestation Small for gestational dates Maternal diabetes Hyperinsulinaemia of the baby Hypothermia Mother using beta blocker such as labetalol

Question 16

His newborn examination (‘24 hour baby check’) is carried out at 26 hours of age. On examination he is noted to look jaundiced (skin and sclera). 9. What risk factors are present for jaundice in this case?

Answer 16

It is unlikely that the jaundice is due to HepC as the baby would be unlikely to have liver inflammation to cause the increased bilirubin at this age As the mother has the Anti-Cw antibodies which are known to be a less frequent cause of haemolytic disease of the newborn - this will probably be the main risk factor for jaundice

Question 17

10. What investigations are required at this stage to determine the cause of the babies jaundice?

Answer 17

Full blood count Serum bilirubin Direct Coomb’s test - check to see if antibodies are present causing the jaundice or if it is physiological

Question 18

When is jaundice said to be physiological?

Answer 18

Concern if jaundice in first 24 hours Physiological jaundice appears usually appears after 48 hours and clears by 14 days after birth

Question 19

His SBR is 250mmol/L. 12. Does this baby require phototherapy? (Use bilirubin plotting chart) Sya for example the baby had the bloods taken and analysed at 26 hours

Answer 19

The baby with a bilirubin of 250mmol/L at 26 hours requires phototherapy

Question 20

How does phottherapy work? What are some of its side effects?

Answer 20

It works by converting the insoluble unoconjugated trans-bilirubin isomer into the soluble cis isomer without the need for conjugation - the photoisomers can then be excreted in the bile Some side effects Dehydration, skin rash,eye damage

Question 21

13. How can phototherapy be delivered? Two different ways

Answer 21

There are two main types of phototherapy. conventional phototherapy – where your baby is laid under a halogen or fluorescent lamp with their eyes covered fibreoptic phototherapy – where your baby lies on a blanket that incorporates fibreoptic cables; light travels through the fibreoptic cables and shines on to your baby’s back

Question 22

How is exchange transfusion delivered?

Answer 22

This is delivered by a line through the umbilicus where blood is taken out and new blood is put in - approx twice the neonates blood volume

Question 23

WHat is prolonged jaundice known as in term and preterm babies?

Answer 23

Term Prolonged jaundice is greater than 14 days Pre-term Prolonged jaundice is greater than 21 days

Question 24

14. Hepatitis B vaccination is also discussed at the neonatal examination with his mother. Why is her baby being offered the first dose of Hepatitis B vaccine in hospital rather than at 8 weeks as part of the routine immunisation schedule?

Answer 24

This is offered because there is a risk that the mother may have more than just the hepC BBV - therefore heptitis B immunoglobulin and hep B vaccine first dose given within 12 hours of life

Question 25

Increased concern Another midwife then calls to say that she is concerned the baby is not feeding great and is concerned he is showing signs of withdrawl. On review his NAS scores have been 7-8 for the preceding 12 hours. Baby is now 40 hours old. On reviewing the NEWS chart his respiratory rate (RR) has been documented as over 80 for the past 8 hours. What is a NAS score?

Answer 25

A NAS score is a neonatal abstinence score - it is an overarching term for a neonate who is withdrawing due to drugs the mother may have been non during pregnancy

Question 26

What is the normal neonatal respiratory rate?

Answer 26

Normal neonatal respiratory rate is 40-60 -so 80breaths/min is far too fast in this baby

Question 27

What are different causes of tachypnoea in the newborn?

Answer 27

Transient tachypnoea of the newborn Respiratory distress syndrome Pneumothorax Infection Pneumonia Withdrawal

Question 28

Infection is a big risk factor for tachypnoea What are risk factors for infection in the neonate? What is given for PPROM?

Answer 28

Pre-term premature rupture of membranes - greater than 24 hours before labour is a risk factor - give erythromycin to prevent infection Group B strep in the pregnancy

Question 29

The baby is reviewed and the team decides to admit him to the NICU for further monitoring and investigation On admission 18. His mother asks how long he will be in NICU for, what should you say? For a couple of days 19. She also asks if there is anything she can do to help, the nurses discuss expressing milk for feeding. Why could breastmilk be beneficial in this case? Maternal substance abuse – currently on methadone and valium detox programme

Answer 29

Could be beneficial as it will help the baby not have the methadone withdrawal or the valium withdrawal as it will be passed through the breast milk Also provides the baby with protection against different infections eg otitis media, gastorenteritis atopy

Question 30

The baby is reviewed and the team decides to admit him to the NICU for further monitoring and investigation 20. What investigations should be carried out on admission

Answer 30

Baby is still tachypnoeic and was jaundiced Measure LFTs CXR to see if it is a pulmonary cause FBCs - check haemoglobin levels for anaemia as well as WCC for signs of infection

Question 31

Progress on NICU There is ongoing concern from nursing staff regarding Neonatal Abstinence Syndrome (NAS). Admission score was 9. 22. How are infants scored for NAS? Withdrawal scoring is an objective measure that allows you to see change in the condition over time – attaches a number to the various symptoms over time 23. What can be done to minimise the effects of NAS?

Answer 31

To minimise the effects of neonatal abstinence syndrome - give the baby what is causing the withdrawal

Question 32

IN the babies case it is vallium (another name for diazepam) and methadone withdrawal causing the symptoms of breathlessness in the baby, what can therefore be given?

Answer 32

Morphine or phenobarbital may be necessary to help reduce the symptoms due to neonatal abstinence syndrome

Question 33

To find out what is cuasing the withdrawal – take a history, toxicology screen (urine only gives acute picture), can do toxicology on meconium to see what baby has been exposed to throughout Make sure baby is hydrated and comfortable, warm and fed On day 5 his weight is noted to be 2140g. Oriiginal weight - 2300g 26. What is the percentage weight loss for this baby? 27. His mum is concerned about the weight loss, what should staff tell her?

Answer 33

%weight loss is approx 7% - it is normal for a baby to lose up to 10% of his weight in the first few days after birth Tell mum this

Question 34

28. He also has his ‘Guthrie Card/Newborn Screening card carried out. What conditions is this screening for?

Answer 34

Sickle cell anaemia Cyctic fibrosis Congenital hypothyroidism Phenylketonuria Medium Chain Acetyl CoA Dehydrogenase deficiency Maple syrup urine disease Isovalaeric acidemia type 1 Glutaric aciduria type 1 Homocysteinuria

Question 35

Following discharge GP calls on day 15 of life to say that he still looks jaundiced, review is arranged. 30. What is the definition of prolonged jaundice in term and preterm infants?

Answer 35

Physiological jaundice should settle by 14 days in term and 21 days in preterm

Question 36

Name some causes of prolonged jaundice?

Answer 36

Congenital hypothyroidism Biliary tract atresia Infection

Question 37

What is biliary atresia?

Answer 37

Serious condition due to failure to form a proper extrahepatic biliary tree therefore cirrhosis of the liver occurs due to biliary obstruction

Question 38

When examining the serum bilirubin Why is it important to ask for both unconjugated and conjugated bilirubin results?

Answer 38

This is because physiological jaundice can only be unconjugated jaundice build up Unconjugated jaundice however can cause either physiological or pathological COnjugated biliruibin build up is always pathological jaundice

Question 39

What is usually the cause of a conjugated jaundice build up?

Answer 39

Usually due to obstruction eg biliary atresia, cystic fibrosis etc