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Paediatrics > Neonataology > Flashcards

Neonataology Flashcards

1
Q

When does the CVS start to develop?

A

End of third week

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2
Q

When does the heart start beating?

A

End of fourth week

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3
Q

What is the critical period for development of the heart?

A

20 to 50th day after fertilisation

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4
Q

What is the ductus venosus?

A

Vein that comes off of the umbilical vein that shunts a portion of oxygenated blood coming from the placenta directly into the IVC (bypassing the liver)

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5
Q

What is the foramen ovale?

A

Shunt between the R and L atrium - allowing blood to bypass the pulmonary circulation

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6
Q

What is the patent ductus arteriosus?

A

Connects pulmonary artery to the descending aorta - allowing blood to bypass the pulmonary circulation

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7
Q

What is normal SaO2 in foetal body?

A

60-70%

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8
Q

What are the functions of the ductus arteriosus?

A

Protects lungs against circulatory overload
Allows the R ventricle to strengthen
Carries low oxygen saturated blood

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9
Q

How is blood flow regulated in the ductus venosus? What kind of blood is mostly carried in the ductus venosus?

A

Oxygenated blood regulated via sphincters

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10
Q

What do the foramen ovale and ductus arteriosus become after birth?

A

Ligamentum arteriosum and fossa ovalis

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11
Q

What is the normal BP of a 1h old?

A

70/44

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12
Q

What is the normal BP of a 1 day old?

A

70+/-9/42+/-12

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13
Q

What is the normal BP of a 3 day old?

A

77+/-12/49+/-10

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14
Q

What is the normal RR of a newborn?

A

30-60m

Periodical breathing

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15
Q

What is the normal HR of a newborn?

A

120-160bmp
Tachycardia is over 160
Bradycardia is <100

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16
Q

Why are newborns purely reliant on metabolic production of heat?

A

Inability to shiver

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17
Q

What does cold stress lead to in babies?

A

Lipolysis and heat production

Brown fat well innervated by sympathetic neurons

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18
Q

Define radiation of heat

A

Heat dissipated to colder objects

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19
Q

Define convection of heat

A

Heat loss by moving air

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20
Q

Why is evaporation of heat important in newborns?

A

We are born in water

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21
Q

What is conduction?

A

Heat loss to the surface on which the baby lies

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22
Q

A newborn does not pass urine for 24 hours - what does this mean?

A

It is normal

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23
Q

Weight loss of up to what is normal in the newborn? What is the weight loss due to?

A

10%
Due to shift of interstitial fluid to intravascular
Diuresis

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24
Q

When does physiological jaundice occur?

A

Day 2-3 of life

Disappears within 7-10 days of life in term infants (up to 21 in prem babies)

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25
Q

Where does most bilirubin come from?

A

Metabolism of Hb

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26
Q

Where is bilirubin conjugated?

A

Liver

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27
Q

What is the most serious complication of jaundice?

A

Kernicterus

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28
Q

What type of bilirubin is able to cross the BBB to cause kernicterus?

A

Unconjugated

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29
Q

How does fluid balance differ in neonates compared with adults?

A

Neonates have less body fat, increased loss of fluids via kidney (slower GFR, reduce Na absorption, decreased ability to concentrate or dilute urine)
Increased insensible water loss (via immature skin and breathing)

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30
Q

Define IUGR

A

<10th centile

Severe IUGR - <0.4th centile

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31
Q

What are the groups of causes for small for dates baby?

A

Maternal
Foetal
Placental
Other

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32
Q

Give an example of a maternal causes of small for dates babies

A

Maternal pre-eclamptic toxaemia (PET)

Smoking

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33
Q

Give two examples of a foetal cause of small for dates babies

A

Chromosomal syndromes, e.g. Edwards syndrome

Foetal infection, e.g. CMV

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34
Q

Give an example of a placental cause of small for dates babies

A

Placental abruption

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35
Q

Give an example of another cause for small for dates babies

A

Twin pregnancy

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36
Q

What are the common problems small for dates babies face?

A 
Perinatal hypoxia
Hypoglycaemia 
Hypothermia
Polycythaemia
Thrombocytopenia
GI problems (e.g. feeds) 
Infection
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37
Q

What are some long term problems associated with small for dates babies?

A

HTN, reduced growth, obesity, ischaemia heart disease

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38
Q

Define pre-term baby

A

<37w

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39
Q

Define extremely pre-term baby

A

<28w

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40
Q

Define low birth weight

A

<2.5kg

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41
Q

Define v. low birth weight

A

<1.5kg

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42
Q

Define extremely low birth weight

A

<1kg

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43
Q

Which systems are affected by prematurity?

A

All of them

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44
Q

What respiratory issue are premature babies more at risk of?

A

IRDS

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45
Q

How do you prevent IRDS?

A

Antenatal steroids

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46
Q

How do you treat IRDS?

A

Surfactant
Early extubation and non-invasive CPAP
Minimal ventilation

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47
Q

What minor respiratory problems are very common in premature babies?

A

Apnoea, irregular breathing, desaturations

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48
Q

How do we treat the minor respiratory problems in premature babies?

A

Caffeine

N-CPAP

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49
Q

What brain issue are premature babies more at risk of?

A

Intraventricular haemorrhage

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50
Q

How can you reduce the risk of intraventricular haemorrhage in premature babies?

A

Antenatal steroids

Delayed cord clamping

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51
Q

How do you treat intraventricular haemorrhage?

A

Sympthomatic

Drainage?

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52
Q

Why is intraventricular haemorrhage more common in premature babies?

A

Unsupported BVs in the ependymal germinal matrix and unstable BP assoc. with birth trauma and respiratory distress

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53
Q

What are signs of an intraventricular haemorrhage?

A

Seizures

Bulging fontanelle

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54
Q

What is the best investigation for intraventricular haemorrhage?

A

USS

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55
Q

What is peri-ventricular leukomalacia?

A

Necrosis of white matter in later ventricles

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56
Q

What is the role of the ductus arteriosus in utero?

A

It is a diversion for blood from the pulmonary trunk to the foetal aorta to avoid passage through the lungs

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57
Q

Describe the pathophysiology of PDA

A

Pressure in the aorta is greater than that in the pulmonary artery and so there is a L to R shunt
This means there is additional blood going to the pulmonary circulation –> over-perfusion of the lungs and lung oedema & stealing from the systemic circulation –> systemic ischaemia

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58
Q

What are the consequences of PDA?

A

Worsening of respiratory symptoms
Retention of fluids (low renal perfusion)
GI problems (e.g. GE ischaemia)

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59
Q

What are the symptoms of PDA?

A

Symptoms rare unless there is CCF or pulmonary hypertension

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60
Q

What are the signs of PDA?

A

Continuous machine murmur below L clavicle, thrill, collapsing pulse, FFT, pneumonias, loud S2.

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61
Q

How do you treat PDA?

A

Ibruprofen

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62
Q

What GI problem are premature babies more at risk of?

A

Necrotising entero-colitis

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63
Q

What occurs in NEC?

A

Ischaemic and inflammatory changes

Necrosis of the bowel

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64
Q

How do you manage NEC?

A

Surgery often req.

Antibiotics and parenteral nutrition may suffice

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65
Q

Why is nutrition so important in prems?

A

They have huge nutritional requirements

And a lot of growing to do

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66
Q

True or false:

Only 1/2 of all premature babies are entirely normal at 6 years of age

A

False

Only 1/6 are entirely normal at 6y

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67
Q

What are milia?

A

Raised bumps on the skin

Thought to be caused by damage to the skin

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68
Q

What is milaria?

A

Sweat rash

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69
Q

What is erythema toxicum neonatorum?

A

A benign self-limited maculopapular rash in healthy neonates
Rash fades by end of 1st week
No Rx req.
Cause unknown

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70
Q

What is sebaceous naevus?

A

Hairless plaque that typically occurs on the scalp

71
Q

What are capillary haemangiomas?

A

Benign tumour due to abnormal growth of capillaries

72
Q

What are Mongolian blue spots?

A

Pigmented slate grey birth marks
Due to a collection of melanocytes
Usually disappear after 4y
Often found in lower back/buttocks

73
Q

What are port wine stains?

A

Birthmark caused by capillary malformation in the skin

74
Q

What are stork marks?

A

Flat red or pink patches that appear on the babies forehead, neck or eyelids at birth
Gradually fades w.i. 1st 2y (facial lesions tend to fade more than occipital ones)
Most common type of vascular birth mark

75
Q

What are giant melanocytic naevi?

A

Large brown/black moles present from birth

Due to overgrowth of pigment cells in the skin

76
Q

What are café au lait spots?

A

Coffee coloured skin patches

>6 before age 5y may indicate neurofibromatosis

77
Q

What condition affecting pigmentation of the skin affects most newborns?

A

Physiological jaundice

78
Q

What causes physiological jaundice?

A

Increased RBC breakdown
Immaturity of hepatic enzymes
–> unconjugated hyperbilirubinaemia

79
Q

What can worsen hyperbilirubinaemia in newborns?

A

Dehydration if feeding is delayed

80
Q

Onset of jaundice in the first 24 hours of life is always pathological/physiological

A

Pathological

81
Q

Why is it very important to treat severe neonatal unconjugated hyperbiilirubinaemia?

A

To prevent bilirubin encephalopathy or kernicterus

82
Q

What is kernicterus?

A

Brain damage due to deposition of bilirubin in the basal ganglia

83
Q

Early evaluation of conjugated hyperbilirubinaemia (>20mmol/L) is important to allow early diagnosis of what condition?

A

Biliary atresia

84
Q

Apart from jaundice in the first 24h, in what other setting would jaundice require further investigation?

A

If it persists >24h

85
Q

What is plethora?

A

Redness of the skin

86
Q

What may cause plethora in a neonate?

A

Polycythaemia

87
Q

Bluing of the skin in a newborn may indicate what?

A

Central/peripheral cyanosis

88
Q

In which groups of people are Mongolian blue spots most common?

A

Races with pigmented skin

89
Q

What are the causes of jaundice in the first 24h?

A

Haemolytic (e.g. G6PD, spherocytosis, rhesus incompatibility, ABO incompatibility)
ToRCH (congenital infections)

90
Q

What are the causes of jaundice from the 2nd day to the 3rd week?

A 
Physiological (gone after 1st week) 
Breast milk 
Sepsis
Polycythaemia 
Cephalhaematoma 
Crigler-Najjar syndrome
Haemolytic disorders
91
Q

What are the causes of jaundice after the 3rd week?

A

Breast milk
Hypothyroidism
Pyloric stenosis
Cholestasis

92
Q

How do you treat jaundice in neonates?

A

Treat underlying cause
Hydrate
Phototherapy or exchange transfusion
Immunoglobulin

93
Q

What should you use when treating neonatal jaundice?

A

Phototherapy chart to decide if using phototherapy or exchange transfusion based on bilirubin and age

94
Q

What babies are at risk of hypoglycaemia?

A

Those with limited glucose supply (premature babies, perinatal stress)
Hyperinsulinism - infants of diabetic mothers
Increased glucose utilisation - sepsis, hypothermia, small for gestational age

95
Q

What are symptoms of hypoglycaemia?

A 
Jitteriness
Hypothermia
Temp instability
Lethargy 
Hypotonia
Apnoea, irregular respirations
Poor suck/feeding
Vomiting
High pitched or weak cry 
Seizures

May be asymptomatic

96
Q

Define hypoglycaemia in neonates

A

<2.6mmol/L

97
Q

When might bedside blood glucose testing be inaccurate?

A

If poor perfusion/polycythaemia

98
Q

What babies are most vulnerable to hypothermia?

A

Low birth weight

Those requiring prolonged resus

99
Q

What is the energy triangle?

A

The main energy deficit for neonates is preventing hypoglycaemia, hypothermia and hypoxia

100
Q

How is heat lost in newborns?

A

Via conduction, convection, evaporation, radiation

101
Q

What is evaporation?

A

Loss of heat when liquid is converted into vapour (e.g. wet skin, wet nappy)

102
Q

What is conduction?

A

Loss of heat from the body surface to cooler surface in direct contact

103
Q

What is convection?

A

Loss of heat from body surface to cooler air

104
Q

What is radiation?

A

Loss of heat from body surface to a cooler solid surface that is not in direct contact but in close proximity to the body

105
Q

How to do you deal with a baby in cold stress?

A 
Dry quickly
Remove wet linens
Use warm towels/blankets
Provide radiant warmer heat
Use heated/humidified oxygen
106
Q

What are tongue ties?

A

Short/thickened frenulum attaching anteriorly to the base of the tongue

107
Q

How do you Rx tongue ties?

A

Mostly not needed
If restriction of tongue protrusion beyond alveolar margins/heavy grooving of tip of tongue/feeding affected –> frenotomy

108
Q

What is the commonest reason for admission to NNU?

A

Respiratory distress

109
Q

How do you examine a neonate in respiratory distress?

A

RR
Increased effort - ?grunting, ?retractions, ?nasal flaring
Colour
O2 sats

110
Q

Where should you assess for retractions in a neonate in respiratory distress?

A

Substernal
Subcostal
Intercostal
Suprasternal

111
Q

What is cleft lip associated with?

A

Cleft palate

112
Q

What are the types of cleft lip?

A

Incomplete (small gap in lip)
Complete (continue into nose)
Unilateral (L most common)
Bilateral

113
Q

What causes cleft lip?

A

Failure of maxillary and medial nasal processes to merge during 5th week of gestation

114
Q

What issues are caused by cleft lip?

A

Feeding issues (need special bottles & teats)
Airway problems
Associated abnormalities

115
Q

What extra things should you do for a neonate with a cleft lip?

A

Hearing screen
Cardiac echo
Think about trisomies

116
Q

What should you always check in the eyes of a neonate?

A

Red reflexes

117
Q

What two conditions should you check for in neonates?

A

Cataracts

Retinoblastoma

118
Q

What are cataracts?

A

Lens opacifications
Can lead to blindness
May req. lens removal & artificial lens

119
Q

What are retinoblastomas?

A

Rare eye cancer that can be treated easily if picked up early

120
Q

How do children with retinoblastomas tend to present?

A

If bilateral tend to present earlier

Leukocoria (white pupillary reflex), strabismus, red eye and reduced vision

121
Q

How do you treat retinoblastoma?

A

Laser therapy, chemo, surgical removal of eye

122
Q

5% of kids with retinoblastoma have what?

A

Deletions of chromosome 13q14 and present with dysmorphic features and FTT

123
Q

What may spinal dimples on neonates indicate?

A

Serious abnormality involving the spine, e.g. spina bifida occulta
May also indicate a kidney problem

124
Q

Under what circumstances would you do an USS & MRI to rule out a serious diagnosis if there was a spinal dimple?

A

If dimple is large, red, swollen, off midline, higher than the sacral area, pigmented, tender or accompanied by fluid

125
Q

What are cephalohaematomas?

A

Localised swellings over one or birth sides of the head
Maximal at 3rd/4th day of life
Soft, non-translucent and limited by cranial bones
Haemorrhage is underneath pericranium

126
Q

How do you treat cephalohaematomas?

A

No Rx required and resolves in 3-4 weeks

127
Q

What is cephalohaematoma associated with?

A

Increased haemolysis & therefore prolonged infant jaundice
NOT an intracranial bleed!

128
Q

What is caput succedaneum?

A

Serosanginous, s/c fluid collected with poorly defined margins

129
Q

What causes caput succedaneum?

A

Pressure of presenting part of the scalp against the dilating cervix during delivery leads to scalp swelling that extends over the mid and suture lines & is assoc with head moulding
Resolves in first few days

130
Q

What are talipes?

A

Club foot

Can be medial (varus), lateral (valgus) deviation of the foot or equinus

131
Q

How do you Rx varus/valgus talipes?

A

Often just req. physio

132
Q

What Rx do fixed talipes req?

A

Vigorous manipulation, strapping, casting, surgery

133
Q

What are significant talipes related to?

A

DDH

134
Q

What is the goal of treating DDH?

A

Relocate femur head to acetabulum so hip develops normally

135
Q

How do you Rx DDH?

A

Pavlik harness

Surgical reduction

136
Q

What features are characteristic of trisomy 21?

A 
Dysmorphism
Hypotonia
Cardiac defects
Learning problems
Haematological problems
Thyroid problems
137
Q

What dysmorphisms are related to trisomy 21?

A

Low set ears, downward slanting palpebral fissures, epicanthic folds, single palmar creases, wide sandal gap

138
Q

What are the symptoms of sepsis in neonates?

A 
Baby pyrexia/hypothermia
Poor feeding
Lethargy 
Early jaundice
Hypoglycaemia
Hyperglycaemia
Asymptomatic
139
Q

What things put neonates at higher risks of sepsis?

A

Maternal pyrexia
Maternal GBS carriage
Premature rupture of the membranes

140
Q

How do you manage presumed neonatal sepsis?

A

Admit to NNU
Partial septic screen (FBC, CRP, blood cultures), & blood gas
Consider CXR, LP

Rx: IV penicillin & gentamicin (1st line)

2nd line: IV vancomycin and gentamicin 
Add metronidazole if surgical/ab concerns 
Fluid management and treat acidosis
Monitor vital signs
Support respiratory and CV as req.
141
Q

What are the commonest causes of neonatal sepsis in order?

A
  1. GBS
  2. E. coli
  3. Listeria
  4. CNS
  5. H. influenzae
142
Q

What are the potential complications of GBS sepsis?

A 
Meningitis
DIC
Pneumonia and resp. collapse
Hypotension 
Shock
143
Q

What things tend to cause congenital infections?

A 
ToRCH 
Toxoplamosis
Rubella
CMV 
Herpes
144
Q

What are the potential consequences of congenital infection?

A

IUGR, brain calcifications, neurodevelopmental delay, visual impairment, recurrent infections, bone abnormalities, rashes, hepatosplenomgaly, jaundice, hepatitis…

May cause pregnancy loss/premature delivery

145
Q

What typical rash can congenital infections cause?

A

Blueberry muffin rash

146
Q

What is the characteristic rash of congenital syphilis?

A

Rash on hands and feet

147
Q

How might congenital toxoplasmosis present in later years?

A

Retinitis

148
Q

What may cause respiratory distress in neonates?

A

Sepsis
Transient tachypnoea of the newborn
Meconium aspiration

149
Q

What is transient tachypnoea of the newborn?

A

Delayed clearance of foetal lung fluids

150
Q

What does TTN present like?

A

Presents within 1st hour of life with grunting, tachypnoea, O2 req, normal gases

151
Q

How do you manage TTN?

A 
Supportive
Antibitoics
Fluids
O2
Airway support
152
Q

What will a CXR show in TTN?

A

Fluid in lung dissures
Hyperinflation
Perihilar haziness

153
Q

What are the risk factors for meconium aspiration?

A

Post dates (aged placenta), maternal diabetes, maternal hypertension, difficult labour

154
Q

What are the symptoms of meconium aspiration?

A

Cyanosis, increased WoB, grunting, apnoea, floppiness

155
Q

How do you Ix meconium aspiration?

A

Blood gas, septic screen, CXR

156
Q

What causes meconium aspiration?

A

Near term dates the foetal meconium accumulates in the foetal colon during pregnancy and is passed in utero leading to meconium stained amniotic fluid

Aspiration of meconium usually occurs in utero

157
Q

What are the consequences of meconium aspiration?

A

Airway obstruction, surfactant dysfunction, pulmonary vasoconstriction, infection and chemical pneumonitis

158
Q

How do you manage meconium aspiration?

A 
Suction below cords
Airway support (intubation/ventilation) 
Fluids and antibiotics IV
Surfactant
NO or ECMO (extracorpeal membrane oxygen)
159
Q

Should you be alarmed at a blue baby?

A

Yes - req. urgent Rx

Remember sepsis & resp causes more common than cardiac

160
Q

When does cyanosis occur?

A

When there is >5g/dL of deoxyhaemoglobin

161
Q

How do you Ix the blue baby?

A 
Ex and Hx
Sepsis screen 
Blood gas and glucose
CXR
Pulse oximetry 
ECG 
Echo
162
Q

What are the differential cardiac diagnoses for the blue baby?

A 
Transposition of the great arteries
Tetralogy of fallots
Total Anomalous Pulmonary Venous Drainage 
Hypoplastic left heart valve syndrome
Tricuspid atresia
Truncus arteriosus
Pulmonary atresia
163
Q

How do you Rx hypoglycaemia in the neonate?

A 
Enteral feeds my be ok
Monitor BG
Start 10% glucose IV 
Increase fluids
Increase glucose concentration (central IV access) 
Glucagon 
Hydrocortisone
164
Q

Why are infants born to mothers with diabetes at risk of neonatal hypoglycaemia?

A

Maternal hyperglycaemia causes beta cell hyperplasia of pancreas and hyperinsulinaemia in foetus which lasts for up to 48h after birth

165
Q

How do you manage the hypothermic baby?

A

If unable to maintain temp on PNW admit to place in incubator
Sepsis screen & antibx
Consider checking thyroid function
Monitor BG

166
Q

What is birth asphyxia?

A

Lack of oxygen at or around birth that leads to multiorgan dysfunction

167
Q

What are the causes of birth asphyxia?

A 
Placental problem
Long, difficult delivery 
Umbilical cord prolapse
Infection 
Neonatal airway problem
Neonatal anaemia
168
Q

What are the stages of birth asphyxia?

A

1st:

  • W/I mins w/o O2
  • Cell damage occurs with lack of blood flow and O2

2nd

  • Reperfusion injury
  • Can last days-wks
  • Toxins released from damaged cells
169
Q

What is HIE?

A

Hypoxic-ischaemia encephalopathy

Brain injury secondary to hypoxic-ischaemic insult

170
Q

How do you manage HIE?

A

Supportive
Therapeutic hypothermia (cooling) improves outcomes
Treat seizures
Cardiac & resp support
Monitor for liver/renal failure
Fluid restriction (to prevent cerebral oedema)

171
Q

What are causes of failure to pass stool?

A 
Constipation
Large bowel atresia
Imperforate anus (+/- fistula)
Hirschsprungs disease
Meconium ileus
172
Q

What should meconium ileus make you think of?

A

CF

173
Q

Diaphragmatic hernia may also be associated with what?

A

Pulmonary hypoplasia

174
Q

What is the management of diaphragmatic hernia?

A

Intubation at birth
Respiratory support
Surgery
ECMO

Paediatrics (35 decks)

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