Neonatology

Question 1

When should the NIPE be performed?

Answer 1

Within 72h of birth

Repeated at 6-8w by GP

Question 2

Brief overview of NIPE (9)

Answer 2

1) Head: circumference, fontanelles, symmetry of skull

2) Face: dysmorphic features, check palate, ears

3) Eyes: jaundice, red reflex

4) Arms: digits, palmar crease, movement

5) Chest: murmur

6) Abdomen: organomegaly, distension, masses

7) Genitalia & anus: external genitalia, hypospadias, observe anus is present and adequately patent

8) Hips: femoral pulses, Barlow’s & Ortolani’s

9) Legs: digits, talipes, movement

10) Back & reflexes: scoliosis, dimples, hair tufts, Moro reflex

Extras: birthmarks

Question 3

3 key risk factors for congenital hip dysplasia?

Answer 3

1) Breech
2) Female
3) FH

Question 4

Cause of unilateral vs bilateral absemt red reflex?

Answer 4

Unilateral - retinoblastoma

Bilateral - congenital cataracts

Question 5

What % of babies present with jaundice within the first week of life?

Answer 5

60%

Question 6

Lifespan of newborn RBCs: term & preterm?

Answer 6

Term neonate: 60-90 days

Preterm neonate: 35-50 days

Question 7

Describe how bilirubin is formed

Answer 7

1) RBC breakdown into haem & globin

2) Haem breakdown into iron & protoporphyrin

3) Protoporphyrin breakdown into unconjugated bilirubin (+ albumin)

4) Conjugated by the liver (UGT enzyme) into conjugated bilirubin

5) Transported to gall bladder via bile duct

Question 8

Is physiological jaundice normally unconjugated or conjugated hyperbilirubinaemia?

Answer 8

ALWAYS unconjugated hyperbilirubinaemia

Question 9

When does physiological jaundice resolve?

Answer 9

Term: <14 days

Preterm: <21 days

Question 10

Cause of physiological jaundice?

Answer 10

Short lifespan of newborn RBCs & insufficient hepatic bilirubin metabolism due to immature liver enzymes (UGT).

Results in increased enterohepatic circulation of bilirubin.

Question 11

What blood tests are indicated for all infants <28 days presenting with jaundice?

Answer 11

1) LFTs (includes total bilirubin)

2) Bilirubin profile - unconjugated & conjugated levels

3) FBC

4) Clotting screen

5) G&S

6) Direct Coombs test

7) Blood cultures

Question 12

What is kernicterus?

Answer 12

Bilirubin-induced neurological damage, creates cerebral palsy type picture.

UNconjugated bilirubin (as can cross BBB)

Question 13

What is the commonest cause of prolonged jaundice (>2 weeks)?

Answer 13

Breast milk jaundice

Question 14

When does breast milk jaundice ALWAYS resolve by?

Answer 14

Typically resolves by 1 month, ALWAYS resolves by 2 months.

Question 15

2 key red flags for pathological jaundice?

Answer 15

1) Onset <24h (sepsis, HDN)

2) Onset after >2 weeks of life

Question 16

2 causes of HDN?

Answer 16

1) Rhesus incompatibility: less common, more severe

2) ABO incompatibility: more common, less severe

Question 17

Hepatosplenomegaly in ABO vs rhesus incompatibility?

Answer 17

ABO - rare

Rhesus - hepatosplenomegaly prominent due to increased demand on immature hepatocytes

Question 18

What test should be done in all cases of jaundice <24h?

Answer 18

Coombs test

Question 19

Coombs test result in Rhesus vs ABO incompatibility?

Answer 19

Rhesus - strongly positive

ABO - weakly positive

Question 20

What does the Coombs test involve?

Answer 20

Detects autoantibodies against RBCs:
- direct assesses antibodies on surface of RBC
- indirect detects unbound antibodies to RBCs in serum

Agglutination = positive test

Question 21

Why is jaundice present so soon after birth in HDN?

Answer 21

As haemolysis has been occurring in utero

Question 22

What is the only examinable cause of conjugated hyperbilirubinaemia?

Answer 22

Biliary atresia

Question 23

When does jaundice caused by biliary atresia typically present?

Answer 23

AFTER 14 days of life

Question 24

Pathophysiology in biliary atresia?

Answer 24

1) Obstruction in bile flow, due to obstructed or absent lumen (‘atresia’)

2) Bile starts to accumulate in biliary tree

3) Pressure increases until bile escapes through tight junctions lining biliary tree

4) Escapes into systemic circulation

Question 25

Classic presentation of biliary atresia?

Answer 25

1) Jaundice onset >14 days of life

2) Pale stools

3) Dark urine

4) Distended abdo & hepatosplenomegaly

Question 26

What procedure is indicated in biliary atresia?

Answer 26

Kasai hepatoportoenterostomy –> best outcome if performed <2 months of life

Note - many will go on to require a liver transplant later (by 2 years old)

Question 27

What is surfactant produced by?

Answer 27

Type 2 pneumocytes

Question 28

Role of surfactant?

Answer 28

Acts to reduce surface tension and prevent airway collapse

Question 29

When does surfactant production begin?

Answer 29

24-28w gestation

Question 30

Mx of RDS?

Answer 30

CPAP +/- artificial surfactant (in NICU)

Question 31

Classic presentation of RDS?

Answer 31

• preterm <1 hour old
• increased work of breathing - grunting, tachypnoea
• cyanosis
• tachycardia
• high O2 requirement

Question 32

What is the key risk factor for NEC?

Answer 32

Prematurity (rarely ever seen in term babies)

Question 33

What is NEC?

Answer 33

Inflammation of intestinal wall.

Progression to bowel ischaemia, inflammation, necrosis and perforation.

Question 34

Classic presentation of NEC?

Answer 34

• preterm
• 2nd to 3rd week of life
• poor feeding
• abdo distension & tenderness
• bloody stools
• perforation: fever, rigid abdomen, vomiting, shocked

Question 35

1st line investigation in NEC?

Answer 35

AXR

Question 36

What will AXR show in NEC?

Answer 36

1) Pneumatosis intestinalis (air in intestinal wall)

2) +/- pneumoperitoneum and free gas (if perforation)

Question 37

Mx of NEC?

Answer 37

1) ABCDE

2) Bowel rest: NBM, TPN

3) IV Abx

4) If perforation –> emergency resection