Introduction to Neonatology Flashcards

Question

normal vital signs of a full term new born: BP

Answer 1

* 1 hr 70/44 * 1 day 70 +/- 9 / 42 +/-12 * 3 days 77 +/- 12 / 49 +/- 10

Answer 2

* 30-60/min | * Periodical breathing

Answer 3

* Normal 120-160 bpm * Tachycardia > 160 bpm * Bradycardia <100 bpm

Answer 4

In the womb maternal thermoregulation maintains the babies temperature. New-born babies lack shivering thermogenesis thus need a metabolic production of the heat. Brown fat is well innervated by sympathetic neurones. Cold stress leads to lipolysis and heat production.

Answer 5

``` • Radiation o Heat dissipated to colder objects • Convection o Heat loss by moving air • Evaporation o We are born in the water • Conduction o Heat loss to surface on which baby lies ```

Answer 6

2-3 days of life

Answer 7

7-10 DOL in term | up 21 in premature

Answer 8

75% bilirubin comes from haemoglobin. Metabolised, conjugated in liver. Bilirubin is lipid soluble thus crosses haemato-encephalic barrier. At high concentrations cause irreversible changes in the brain – kernicterus

Answer 9

Blue light converts bilirubin to water soluble form and increases oxidation of bilirubin.

Answer 10

Full term infant is able to maintain fluid / electrolyte balance. Weight loss up to 10% is normal. Loss is due to: shift of interstitial fluid to intravascular and diuresis. It is normal not to pass urine for the first 24 hrs! ``` • Less fat in body composition • Increased loss through kidney: o Slower GFR o Reduced Na reabsorption o Decreased ability to concentrate or dilute urine • Increased Insensible Water Loss (IWL) o Via immature skin and breathing o Physiological IWL is 20-40 ml/kg/day but could be up to 82 ml/kg/day in 750-1000 g ```

Answer 11

* RBC production is 10% of in uterus DOL 7 * Born with - Hb 15-20 g/l * Week 10 - Hb 11.4 g/l * Increase production of Erythropoietin * Week 20 - Hb 12.0 g/l

Answer 12

o Reduced erythropoiesis. | o Bloodletting – most important cause!

Answer 13

jaundice pallor plethora cyanosis

Answer 14

``` benign milia miliaria erythema toxicum neonatorum infections sebaceous naevus ```

Answer 15

``` o Capillary haemangiomas o Mongolian blue sports o Port wine stains o Stork marks o Giant melanocytic naevi o Café au lait spots ```

Answer 16

dehydration

Answer 17

24 hrs of life

Answer 18

Pallor is a clinical sign and not a diagnosis. It suggests anaemia and may be congenital or acquired. Decrease in haemoglobin may be secondary to bleeding internal or external. Decreased production by bone marrow or increased destruction of RBC may also cause anaemia. Disseminated intravascular coagulopathy can also cause it. The most common cause of anaemia in preterm is iatrogenic secondary to blood sampling.

Answer 19

Plethora is a condition marked by an excess volume of blood causing swelling and a reddish complexion. A cause of this might be polycythaemia which has implications in terms of blood viscosity.

Answer 20

This is white papules on the tip of the nose caused by hyperplastic sebaceous glands. The effect of the transplacental hormones. The disappear with desquamation

Answer 21

Miliaria are the result of obstruction to immature sweat glands. They are commonly seen secondary to thermal stress, crops of lesions over the face, scalp and trunk. Miliaria crystallina are superficial vesicles with a diameter of 1-2 mm. The skin is not inflamed. Miliaria rubra aka prickly heat are papules and pustules from obstruction in the mid-epidermis.

Answer 22

The cause this maculo popular rash is unknown but it mostly clears after 1-2 week. It occurs in 30-70% of normal term neonates. It is very rare in the pre term. No treatment is required.

Answer 23

These are relatively rare. Non benign pustular rashes with the commonest cause being staph aureus. Consider herpes.

Answer 24

These are hamartomatous lesions sensitive to androgens. Androgens are produced during puberty causing the lesions to become larger and more wart like. There is risk of malignant degeneration (basal cell carcinoma) in adulthood therefore elective removal should be considered.

Answer 25

Also known as strawberry naevus and intradermal haemangiomas. A cluster of dilated capillaries appear within the 1st month. They are raised and bright red with discrete edges. They can be found on any part of the body. They usually regress after 1st year. They vary in severity from salmon patch

Answer 26

These have a deep vascular component. If vision is under threat then they require treatment. There are a vascular anomaly. Histologically they are abundant endothelial cells with narrow vascular channels. They are the commonest tumours of the eyelids and orbits in childhood.

Answer 27

There are blue-grey pigmentations of the skin. They often affect the lower back and buttock. They result from an accumulation of melanocytes. They are very common is races with pigmented skin. Less obvious as the skin darkens

Answer 28

The port wine stain is dark purple in colour and is located most frequently on the face in the area of distribution of the fifth cranial nerve. There is no tendency for this type of haemangioma to regress spontaneously. Sturge–Weber syndrome is an occasional associated malformation. Also associated with Kippel Trenaunay Weber. Also known as naevus flammeus these are present at birth. They may be flat or slightly raised. Caused by dilated, mature capillaries in the superficial dermis. They do not regress. Treatment is with cosmetic cover; good results can be achieved with the pulsed dye laser.

Answer 29

Also known as naevus simplex these are a light colour capillary dilatation. Commonly found at the back of the neck. May also be found along the midline of the face. They gradually fade within the 1st 2 years. This is a very common flat pink lesion, present at birth. It is usually located on the forehead, eyelids, occiput, neck or midline of the back. It may be V-shaped on the forehead/occiput. Facial lesions fade, occipital tend not to. The lesions are not pathological so there is no active management needed

Answer 30

These are a large area of pigmentation that often becomes hairy later. Rarely there may be a malignant change. Lesions are present at birth, at any site, size and number, but often fade at least to some degree, occasionally dramatically. Patients may develop new lesions after birth. MRI brain and whole spine if more than one lesion, to look for associated neurological melanosis/ structural abnormalities/tumours. Cosmetic implications.

Answer 31

These are common in new-borns and can range from 2mm to 20cm in size. They are typically on unexposed skin. They form as a result of increased melanin in melanocytes, and epidermal cells. they may increase in number with age. 6 or more greater than 0.5cm consider neurofibromatosis.

Answer 32

haemolytic - G6PD spherocytosis | TORCH

Answer 33

``` o Physiological ( gone after 1st wk ) o Breast milk o Sepsis o Polycythaemia o Cephalohematoma o Crigler-Najjar Syndrome o Haemolytic disorders ```

Answer 34

o Breast milk o Hypothyroidism o Pyloric stenosis o Cholestasis

Answer 35

* Bilirubinometer * Se bilirubin (+ conjugated fraction) * FBC * Blood film * Blood group, Coomb’s test

Answer 36

* Treat underlying cause * Hydrate * Phototherapy – NICE guideline charts * Exchange transfusion * Immunoglobulin

Answer 37

* Rare cause of neonatal jaundice * Worry if conjugated fraction > 20 and > 20% * Need to exclude biliary atresia * HIDA scan investigation * Surgery more likely to succeed if performed < 6 weeks of age * High chance that liver transplant will be required

Answer 38

first few days of life decreased alertness hypotonia decreased feeding

Answer 39

variable onset and duration hypertonia of extensor muscles retrocolis opisthotonus

Answer 40

Infants > 1 week of age | hypotonia

Answer 41

* 1st year – hypotonia, hyperreflexia, delayed acquisition of motor milestones * Extrapyramidal – athetosis, chorea, upper limbs > lower limbs * Visual – ocular movements, upward gaze * Auditory – high frequency hearing loss, delayed language * Cognitive – not severely affected * Opisthotonus from kernicterus. This is now rarely seen in developed countries * Macroscopic appearance of brain in a term infant with kernicterus.

Answer 42

``` • Limited glucose supply o Premature babies o Perinatal stress • Hyperinsulinism o Infants of diabetic mothers • Increased glucose utilisation o Small and large for gestational age o Hypothermia o Sepsis ```

Answer 43

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

Answer 44

<2.6 mmol/l

Answer 45

o At low or high levels o When there is poor perfusion o When there is polycythaemia

Answer 46

low birth weight and those requiring prolonged resuscitation

Answer 47

* Short +/- thickened frenulum * Attached anteriorly  base of tongue * Mostly no treatment necessary * Restriction of tongue beyond the alveolar margins or heavy grooving tip of tongue and/or feeding is affected  frenotomy

Answer 48

* Vomiting * Posseting * Mucous vomits * Gastro-oesophageal reflux * Cow’s milk protein intolerance * Bilious vomiting * Failure to pass meconium * Bloody stools * Blood in vomit

Answer 49

stridor | retractions

Answer 50

nose mouth and jaw larynx or trachea bronchi

Answer 51

substernal subcostal intercosta suprasternal

Answer 52

o Floppy upper larynx o Stridor +/- feeding problems o Gets worse at 2-3 months and most resolve without treatment

Answer 53

o Floppy tracheal cartilage o Stridor worst when crying, coughing, feeding o Most commonly affects distal 3rd of trachea o Most improve by 2 years

Answer 54

o Weak bronchial cartilage o Stridor, wheeze, and dyspnoea o More likely to need CPAP +/- tracheostomy

Answer 55

Murmurs are common but most are benign. Timing is important. Assess colour, perfusion and respiratory status. Note location, type and radiation of murmur. Record oxygen saturations and 4 limb blood pressure. Perform a CXR and Echo.

Answer 56

* Always think sepsis * Acrocyanosis * Examination, especially cardiac * Monitor ECG, saturations, BP * Oxygen * Blood gas and baseline bloods * CXR * Echo * Consider prostin and referral to cardiology

Answer 57

* Foetal arrhythmia * Maternal autoantibodies * SVT * Heart block * ECG with rhythm strip * Echo * Discuss with cardiology

Answer 58

Choanal atresia is a congenital malformation where there is a failure to develop a communication between the nasal cavity and the nasopharynx. It can be unilateral and more rarely, bilateral. • Nasal obstruction • Baby is cyanotic at rest. “pinks up” with crying • If bilateral may need oral airway or endotracheal intubation • Oral airway sizes o 00 for small infants o 0 for term or large infants

Answer 59

Very small jaw with tongue obstruction and possible cleft palate. Place prone to move the tongue forward. For respiratory distress insert 2.5mm ET tube nasally with tip visible at back of throat, humidified O2 or use CPAP, may need endotracheal intubation

Answer 60

70% of cleft lip cases also have a cleft palate. It can range from incomplete, small gap in lip, to complete where it continues onto the nose. It can be unilateral or bilateral. Left sided unilateral is most common. 85% of bilateral cleft lips have palatal involvement. Maxillary and medial nasal processes fail to merge, usually around 5 weeks gestation.

Answer 61

The 2 plates of the skull forming the hard palate fail to merge by 9 weeks’ gestation and can occur after lip closure. If the soft palate is also cleft then most times a cleft lip is present. Can be complete (soft and hard palate involved) or incompletes (hole in the roof of the mouth, soft palate involved.

Answer 62

``` • Feeding issues o Special bottles and teats o Can still attempt breast feeding • Airway problems • Associated anomalies o Need hearing screen o Need cardiac echo o Remember trisomies ```

Answer 63

* Lens opacification * If undetected early could lead to blindness * May require no treatment * May require lens removal and artificial lens

Answer 64

Retinoblastoma affects 1 in 20,000 children, which is equivalent to about 45 cases per year in the UK. More than 90% of cases are diagnosed before 5 years of age. Children with bilateral retinoblastoma present earlier (median age 8 months) than the unilateral form (median age 28 months). Presenting signs include leukocoria (white pupillary reflex), strabismus, red eye and reduced vision. Tumours are bilateral in 30% of cases. Five percent have deletions of chromosome 13q14 and present with dysmorphic features and failure to thrive.

Answer 65

This is a common antenatal finding. It is important to prevent renal damage from Vesico-ureteric reflux. There is a protocol for investigation and treatment. Scans at birth and 6 weeks +/- prophylactic antibiotics.

Answer 66

``` • Skin tags o Common o No action required • Urinary meatus • Clitoris o Relatively larger in preterm or IUGR infants ``` Mucosal skin tags are a fold or continuation of the mucosa from the vaginal wall and is often seen in new-born girls. It shrinks and disappears within the first week of life. Vaginal bleeding or pseudo-menstruation is a normal effect of withdrawal from maternal hormones. It can last from 48 hrs to 6 days.

Answer 67

* Undescended testes – requires follow up * Micropenis - <2.5cm term, refer if worried * Hypospadias – proximally displaced urethral meatus * Chordee – ventral curvature of the penis * Torsion – usually antenatal, clinical emergency if acute * Hydrocoeles – benign and no treatment required * Inguinal hernias – more common in preterms, require surgery Undescended testes occurs in 2% of births. 1.5% by 3 months: retractile, palpable and impalpable. Referral for surgery age 1 – 2 years. The average stretched penile length at birth is about 4 cm. 90% of term boys between 2.4 and 5.5cm. refer if seems small. A hypospadic urethra opens anywhere along a line (the urethral groove) running from the tip along the underside (ventral aspect) of the shaft to the junction of the penis and scrotum or perineum. In 1st degree the urethral meatus opens on the underside of the glans penis in about 50-75% of cases. With second degree the urethra opens on the shaft. Around 20% of cases. 30% of cases are 3rd degree where the urethra opens on the perineum. 3rd degree can be associated with chordee or with undescended testes. Chordee exists where there is a ventral curvature of the penis. It can occur along with hypospadias but is can also be isolated. Torsion is uncommon but treatment is required within 6 hours for testis to remain viable. A hard tender testis with sometimes bluish discoloration. Most neonatal cases the testis is already necrotic. Urgent surgical referral. Hydrocoeles are a frequent finding in new-borns. Important on palpation to identify the normally small testicles (approximately 1 cm) as separate entities from the large, smooth-walled fluid collections of hydrocoeles. In contrast to inguinal hernias, common (non-communicating) hydrocoeles cannot be reduced as the fluid is in an enclosed space. Transillumination may be used to assist in making a diagnosis Hernias are common, reducible. Irreducible hernias may strangulate. Early referral for paediatric surgery

Answer 68

• Clearly indeterminate sex o Genitalia clearly ambiguous • Apparent male o Bilateral non-palpable testes in full term new-born o Separation of the scrotal sacs with hypospadias. o Hypospadias concomitant with undescended testicle • Apparent female o Clitoral hypertrophy o Foreshortened vulva with a single opening o Inguinal hernia containing a solid mass ( likely to be a gonad)

Answer 69

* Reassure the parents their child is healthy but, you are not sure of the sex and will ask an experienced doctor to see the baby. * Parents may wish to restrict visitors until the gender has been assigned. * Discuss relocation to single room with the midwife. * Never guess or say (looks like a male or a female) * Ask the Neonatal Registrar/Consultant to see immediately * Dr Mayo, Consultant Paediatrician, & Mr Driver, Consultant in Surgical Paediatrics, would like to be involved early.

Answer 70

• Serum electrolytes and glucose (may need to repeat daily) • Chromosome analysis o Remember phenotype more important than genotype • Pelvic/abdominal ultrasound scan to determine pelvic structures and the presence or absence of gonads. • 17-hydroxyprogesterone • Serum for Testosterone

Answer 71

Benign spinal dimples are indentations in the skin on the lower back just above the buttocks. They are present at time of birth and usually small and shallow. >2% of babies have such dimples. Almost all of these are very minor and do not need any medical treatment. They can reveal a more serious abnormality involving the spine and/or spinal cord, such as spina bifida occulta which is the least serious form of spina bifida. Dimples may also be indicative of a possible kidney problem. If the dimple is large, red, swollen, off midline, higher than sacral area, pigmented, tender or accompanied by fluid  Ultrasounds, and MRI’s are all used to make a clear diagnosis and rule out a more serious condition.

Answer 72

These are localised swelling over one or both sides of the head that becomes maximal in size by the 3rd or 4th DOL. They are soft, non-translucent swellings. Limits are those of one of the cranial bones – usually parietal. Haemorrhage is beneath the pericranium. No treatment is required, and resolution occurs in 3-4 weeks. Occasionally, if the haematoma is very large the increased haemolysis results in increased or prolonged jaundice. No association with intracranial bleeding.

Answer 73

Serosanguinous, subcutaneous fluid collection with poorly defined margins caused by the pressure of the presenting part of the scalp against the dilating cervix during delivery scalp swelling that extends across the midline and over suture lines and associated with head moulding does not usually cause complications and resolves over the first few days.

Answer 74

Unilateral facial nerve palsy is the most common peripheral nerve injury, with an incidence as high as 1.4 per 1000 live births . Injury can result from direct trauma from forceps or from compression of the nerve against the sacral promontory while the head is in the birth canal. Decreased facial movement and forehead wrinkling on the side of the palsy, eyelid elevation, and flattening of the nasolabial folds and corner of the mouth. Crying accentuates the findings, with the most obvious sign being asymmetrical movement of the mouth. The side that appears to droop when crying is the normal side.

Answer 75

Differentiated from facial nerve palsy in that the eye and forehead muscles are unaffected. Congenital deficiency or absence of the depressor anguli oris muscle which controls the downward motion of the lip. Left side of the mouth is affected in nearly 80% of cases. Lip asymmetry may also be apparent when the infant smiles. Other facial features are symmetrical. Frequently an isolated finding. However, may be associated with cardiovascular, musculoskeletal, genitourinary, respiratory defects or 22q11 deletion.

Answer 76

Medial (varus) or lateral (valgus) deviation of the foot is often positional and requires no treatment other than physiotherapy. Fixed talipes requires more vigorous manipulation, strapping, casting or possibly surgery. Babies with significant talipes may also have developmental dysplasia of the hips.

Answer 77

``` • Shallow acetabulum results in femur slipping out of the socket • Risk factors o Breech > 36 weeks o First degree relative with DDH o Multiple birth o Female o 1st child o Large birth weight • Examination o Leg length o General movement of the legs o Groin creases o Ortolani test o Barlow test o Ultrasound ```

Answer 78

``` • Dysmorphism o Low set ears, downward slanting palpebral fissures, epicanthic folds, single palmar creases, wide sandal gap • Hypotonia • Cardiac defects • Learning problems • Haematological problems • Thyroid problems Enquire about serum screening in pregnancy. The child typically present as a floppy neonate with up slanting palpebral fissures, flat facial profile, large fontanelle(s), poor suck and cardiac murmur. 50% have congenital heart disease and there is a twofold increase for all congenital anomalies. Median survival is close to 50 years unless there is a significant cardiac or other malformation. Mean IQ for young adults is 45–50 but this declines later due to early onset dementia. ```

Answer 79

Occur in 7,900 livebirths (increases with maternal age). Genetic aetiology/pathogenesis 47XXorXY+18. Most are due to an error during meiosis and 85% are of maternal origin. The aetiology is associated with increased maternal age. Prematurity is common and many trisomy 18 foetuses are lost spontaneously during pregnancy. The birth weight is low (mean 2240 g) and the head shape is abnormal with a prominent occiput. Limb abnormalities are found with contractures of the fingers, short hallux, prominent heels and sometime a radial deficiency of the forearms. 90% have a congenital heart defect and the sternum is short. Cleft lip and palate, exomphalos and diaphragmatic hernia are common additional malformations

Answer 80

``` sepsis TTN meconium aspiration cardiac hypoglycaemia hypothermia birth asphyxia hypoxic ischaemic encephalopathy • Oesophageal atresia/fistula • Duodenal atresia and other GI atresias • Causes of failure to pass stool • Abdominal wall defects • Diaphragmatic hernia ```

Answer 81

* Baby pyrexia or hypothermia * Poor feeding * Lethargy * Early jaundice * Hypoglycaemia * Hyperglycaemia * Asymptomatic

Answer 82

* PROM * Maternal pyrexia * Maternal GBS carriage

Answer 83

* Admit NNU * 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

Answer 84

``` • Group B streptococcus • E-coli • Listeria • Coag-neg staphylococci (if lines in situ) • Haemophilus influenzae • GBS Sepsis o Early onset – birth to 1 week o Late onset or recurrence – up to 3 months o Symptoms – may be non-specific o May have no risk factors o Complications  Meningitis, DIC, pneumonia and respiratory collapse, hypotension and shock o Prognosis – 4 to 30% mortality ```

Answer 85

``` o IUGR o Brain calcifications o Neurodevelopmental delay o Visual impairment o Recurrent infections ```

Answer 86

TTN is self-limiting and common. It presents within the 1st few hours of life. Clinically the child will be grunting, tachypnoeic, oxygen requirement with normal blood gases. Pathophysiology is a delay in the clearance of foetal lung fluids. Management is supportive with antibiotics, fluids, oxygen and airway support.

Answer 87

Meconium is inhaled into the lungs. Risk factors include: post-dates (aged placenta), maternal diabetes, maternal hypertension and difficult labour. Symptoms are: cyanosis, increased work of breathing, grunting, apnoea and floppiness. Investigations: blood gas, septic screen and CXR.

Answer 88

``` • Suction below cords • Airway support o Intubation and ventilation • Fluids and antibiotics IV • Surfactant • NO or ECMO ```

Answer 89

* Most do well * Some develop PPHN * There is an associated mortality

Answer 90

* Examination and history * Sepsis screen * Blood gas and blood glucose * CXR * Pulse oximetry * ECG * Echo * (hyperoxia test)

Answer 91

* TGA * Tetralogy of Fallot * TAPVD * Hypoplastic left hear syndrome * Tricuspid atresia * Truncus arteriosus * Pulmonary atresia

Answer 92

* ABC * Inotropes as required * Fluid resuscitation * Respiratory support (care with O2) * Prostin (PGE2) * Nitric oxide * Cardiology referral

Answer 93

If requires admission to NNU may still manage with enteral feeds. Monitor blood glucose and start IV 10% glucose. Increase fluids and glucose concentration (central IV access). Glucagon and hydrocortisone

Answer 94

If unable to maintain temperature on PNW admit and place in incubator. Sepsis screen and antibiotics. Consider checking thyroid function. Monitor blood glucose.

Answer 95

In severe jaundice an admission for intensive phototherapy and/or exchange transfusion may be needed. Incubator and IV fluids may be required.

Answer 96

* Placental problems * Long, difficult delivery * Umbilical cord prolapse * Infection * Neonatal airway problem * Neonatal anaemia

Answer 97

o Acute injury = primary energy failure | o Minutes to hours

Answer 98

o Reperfusion | o 6-15 hours

Answer 99

o Delayed injury = secondary energy failure | o Hours to days

Answer 100

* Supportive * Fluid restriction (avoid cerebral oedema) * Monitor for renal and liver failure * Respiratory support * Cardiac support * Treat seizures * Therapeutic hypothermia improves outcomes especially in moderate group

Answer 101

* Baby cooled to 33 degrees for 72 hours * Then rewarmed slowly over 12 hours * Sedated for cooling * Monitored with CFAM * Cranial ultrasounds * MRI at 7-10 days * Neurodevelopmental follow up

Answer 102

``` • Constipation • Large bowel atresia • Imperforate anus o +/- fistula • Hirschsprung’s disease • Meconium ileus o Think cystic fibrosis ```

Answer 103

* 1 in 2500 births * 90% on left * Male > female * Can be syndromic * Usually pulmonary hypoplasia * Intubation at birth * Respiratory support * Surgery * (ECMO)

Introduction to Neonatology Flashcards

(127 cards)