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Year 4 PAEDS > Neonatal > Flashcards

Neonatal Flashcards

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1
Q

What is the difference between cephalhaematoma and caput succedaneum?

A

Both are non-concerning injuries causes by birthing trauma
Caput succedaneum is associated with venous delivery and it extends across suture lines. It is self-limiting
Cephalhaematoma is a subperiosteal bleed limited by suture lines and again it is a bruising associated with instrumental delivery

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2
Q

What is an example of a pathological, concerning head trauma associated with birthing injury?

A

If the birth is particularly traumatic it can cause Intraventricular haemorrhage (IVH)
Bleeding into the ventricles of the brain - as blood pools here it can clot and cause blockage to the drainage of CSF.
This can lead to hydrocephalus

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3
Q

What is the most common nerve palsy associated with traumatic delivery? Describe it and suggest management.

A

ERB’S PALSY - damage to C5, C6 nerve roots - associated with shoulder dystocia
The arm is flaccid, the forearm is pronated and the wrist flexed - WAITER’S TIP
In 2/3 cases full recovery is seen in 6 weeks
Should consider an X-ray to rule out clavicle feature
If recovery is slow then consider physiotherapy referral

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4
Q

What other nerve palsies can occur with traumatic delivery?

A

FACIAL NERVE PALSY - following pressure on the face from maternal ischial spines or forcept
FACIAL ASYMMETRY worse on crying
Majority will recovery within a week or 2 but they might need some ophthalmological input

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5
Q

What are some of the most common fractures for baby’s to get during a traumatic delivery and how should they be managed?

A

CLAVICLE - not uncommon with big babies, they need to be immobilised - have their arm inside their baby grow and usually have healed in a few weeks
AVULSION FRACTURES of the humeral or femoral epiphysis is also not uncommon
SKULL FRACTURES - slight risk with forceps - consider neuro r/v

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6
Q

What is the most common cause of birth asphyxia?

A

Drop in maternal blood flow during delivery

- Excessive haemorrhage

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7
Q

What sorts of problems might birth asphyxia cause?

A

Developmental delay
Intellectual delay
Physical problems e.g. spasticity - CEREBRAL PALSY

RISK OF HYPOXIC ISCHAEMIC ENCEPHALOPATHY (HIE)

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8
Q

What are some risk factors for birth asphyxia?

A 
Elderly or young mothers 
Prolonged rupture of membranes 
Meconium stained fluid 
Multiple births 
Lack of antenatal care 
Low birth weight 
Malpresentation 
Use of oxytocin augmentation in labour 
APH 
Pre-eclampsia and eclampsia 
Anaemia
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9
Q

What causes HIE?

A

PERI-NATAL ASPHYXIA either due to poor pulmonary gas exchange in the newborn or poor placental perfusion in the mother
This leads to hypo and decreased cardio-respiratory effort causing worsening hypoxia, metabolic acidosis and hypo perfusion and end organ ischaemia in the brain - HIE

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10
Q

What are the affects of HIE and what can we do to counter these?

A

Neurodisability as well as death in the infant
Immediate (primary) neuronal death from the hypoxic injury or further death of these tissues might occur when due to re-perfusion injury
We can try and protect/delay this secondary injury with THERAPEUTIC COOLING to induce hypothermia

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11
Q

What are some SPECIFIC causes of HIE?

A

PLACENTA (placental abruption, ruptured uterus)
UMBILICAL BLOOD FLOW (excessive or prolonged uterine contractions, cord compression, cord prolapse, shoulder dystocia
MATERNAL - maternal hypotension or hypertension. This is often associated with intrauterine growth restriction
- Compromised fetus - anaemia, IUGR
- Failure to breath at birth
CAN BE CAUSED BY NEONATAL CONDITION
Inborn error of metabolism
Kernicterus

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12
Q

When and how will we know HIE has occurred (features)?

A

MILD: the infant is irritable, responds excessively to stimulation, staring of the eyes and hyperventilation and impaired feeding
MODERATE: the infant shows marked abnormalities of tone and movement, cannot feed and may have seizures
SEVERE: no normal spontaneous movements or responses to pain. Tone in the limbs may fluctuate between hypertonia and hypotonia, seizures prolonged and not responsive to treatment, multi-organ failure

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13
Q

How should we manage HIE?

A

Resuscitation and stabilisation
Respiratory support
EEG monitoring - helps to identify seizures early and also spot encephalopathy
Treat seizures
Fluid restriction because of renal impairment

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14
Q

What is the prognosis for babies with HIE?

A

Complete recovery can be expected if babies have MILD HIE
In some moderate cases there will be partial recovery in the first 2 weeks (although there is not likely to be any recovery after this time)
PERFORM MRI at day 4 and day 14 - if significant abnormalities exist bilaterally in the basal ganglia, thalamus and internal capsule (lack of myelin) then this is a strong predator of CEREBRAL PALSY

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15
Q

When should APGAR scoring be done?

A

1, 5 and 10 minutes

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16
Q

What are the categories in APGAR scoring and how are they scored?

A

Activity/Muscle tone (none=0, flexed arms and legs=1, active =2)

Pulse (absent=0, <100bpm=1, >100bpm=2)

Grimace/Reflex irritability to stimuli (No response=0, Minimal response=1, prompt response=2)

Appearance/Colour (Blue/pale=0, Pink centrally but with slightly blue peripheries =1, pink all over =2)

Respiration (none=0, infrequent and irregular =1, normal (vigourous cry)=2)

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17
Q

What is a normal APGAR score?

A

An ideally healthy baby should score 10, however scores of 9 and sometimes 8 are normal

Very often even health babies have slightly blue extremities, this loses them a point on appearance but is not often a cause for concern.

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18
Q

In which babies, and when, does necrotising entircolitis (NEC) usually occur?

A

In premature babies and it will often develop in the first few weeks of life

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19
Q

What are some features of NEC?

A 
Stopping tolerating feeds 
Aspiration 
Vomit +/- bile stained 
Abdominal distension 
Fresh blood in the stool
SHOCKED - due to distension and pain
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20
Q

How should we investigate NEC?

A

AXR

  • Will see distended loops of bowel
  • Thickening of the bowel wall due to intra-mural gas
  • Gas in the portal tract
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21
Q

How should we treat NEC?

A 
Stop oral feeding 
TPN 
Broad spectrum abx 
Ventilatory support 
Cardiovascular support 
Danger of BOWEL PERF - refer to surgery
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22
Q

What can be offered antenatally to help prevent NEC?

A

Erythromycin

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23
Q

What is the prognosis in infants with NEC? Long-term complications?

A

Mortality rate is about 20%

LONG TERM SEQUELAE: Strictures, malabsorption, short bowel syndrome as consequence of surgery

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24
Q

What is the first thing you should do when resuscitating a newborn?

A

DRY THE BABY

Then assess breathing, heart rate and tone

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25
After drying it what is the next stage in neonatal resuscitation?
``` Optimise airway (face parallel to surface, ADMINISTER 5 RESCUE BREATHS Repeat this, improving manoeuvres and considering intubation until the chest is seen to rise ```
26
Spontaneous ventilation has recovered what is the next stage in neonatal resuscitation?
Assess for heart beat and if there is none, or it is low (<60bpm) begin chest compression with compression:breath ratio of 3:1 Re-assess for heart beat every 30 seconds until heart rate is >60bpm
27
What would you expect of the saturations of a neonate?
THEY ARE VERY OFTEN VERY LOW and this is not always concerning - check them to see whether they recover Neonates also very often have something called TRANSIENT TACHYPNOEA OF THE NEWBORN (TTN) where grunting or occasional nasal flaring might occur - monitor reps rate and sats and respond accordingly
28
What % of babies are jaundiced and is this always concerning?
60% babies jaundiced - very often this is physiological
29
Should you be concerned about jaundice in the first 24h of life??
YES - jaundice in the first 24h of life is ALWAYS PATHOLOGICAL
30
Describe why physiological jaundice occurs?
When babies are born they have an excess of red blood cells from the mother - this excess leads to high levels of break down meaning the levels of Bilirubin are higher than the immature liver is able to conjugate (low enzyme levels) **remember unconjugated bili is not soluble so you can't excrete it
31
When will physiological jaundice occur?
It will present in the first 2-3 days of life
32
When will physiological jaundice occur and do we need to intervene?
Recover at 2 weeks as the liver matures We don't need to recover as it is usually self-limiting but can take bilirubin levels to see whether it reaches the threshold for treatment particularly common in breast-fed babies (might be slightly dehydrated)
33
What are some causes of early jaundice?
Sepsis, ABO incompatibility and Rh disease | SHOULD INVESTIGATE FOR ALL OF THESE
34
When do we deem it prolonged jaundice?
Once it has lasted for longer than 2 weeks or longer than 3 weeks in a pre-term baby
35
What are some causes of prolonged jaundice?
Biliary atresia Breast-milk jaundice (should investigate for liver disease extensively before just calling it this) G6PD
36
If you do some blood tests and find the bilirubin to be conjugated what does this mean?
This suggests that the cause is LIVER DISEASE (either biliary atresia or neonatal hepatitis) - OBSTRUCTIVE JAUNDICE (pale stools and dark urine)
37
What tests/investigations should we consider in early jaundice?
FBC, cultures, blood groups DCT haemolysis screen
38
How do we decide what treatment we need to give and when we need to give it in neonatal jaundice?
Take their bilirubin levels and plot it on a chart against their age. See if they reach the treatment threshold for phototherapy or even transfusion
39
How often should we check bilirubin levels in neonates with jaundice?
Every 12h if not concerned or every 6-8 if more worried.
40
What are some complications of neonatal jaundice?
bilirubin deposition in the brain leading to a form of cerebral injury called KERNICTERUS - Unconjugated bilirubin collecting in the basal ganglia
41
What are some symptoms of kernicterus?
Poor feeding, irritable, high-pitched cry, lethargy, apnoea, hypotonia, seizures and muscle spasms
42
How does phototherapy work in the treatment of jaundice?
450nm wavelength of light given Converts bilirubin into water soluble pigment that can be excreted in the urine Cover infants eyes and take bilirubin levels every 4-6hrs
43
Why does respiratory distress occur in the newborn?
Occurs in prem babies when there has not been sufficient surfactant production to provide the tension necessary to keep the alveoli open Alveoli collapse leading to poor ventilation of the lung and inadequate gaseous exchange
44
What is done to prevent RDS?
Giving corticosteroids in the likely event of premature delivery
45
If RDS occurs in the newborn how do we treat it?
Give artificial surfactant down ET tubes in prem babies (often done anyway) Oxygen therapy and positive airway pressures
46
How does RDS present?
Might not present straight away but within 4 hours of birth: - TACHYPNOEA (>60) - Laboured breathing (recession, tracheal tug, nasal flaring) - Expiratory grunting - Cyanosis if severe
47
What are some complications of RDS in the newborn?
the extensive oxygen therapy that is given can lead to RETINOPATHY OF PREMATURITY (overgrowth of vessels) RENAL FAILURE
48
What other respiratory system abnormalities can occur int the pre-term baby and when will these stop?
Episodes of bradycardia and apnoea Will occur up to 32 weeks gestation Child stops breathing for 20-30s
49
What causes bradycardia and apnoea in the newborn?
Many causes - infection - hypoxia - anaemia - GORD - aspiration - Hypoglycaemia MIGHT NEED CPAP to treat
50
Why is preventing hypothermia in the newborn?
Hypothermia leads to shivering and increased energy use and hypoxia and hypoglycaemia Pre-term infants vulnerable due to high surface area, little sub cut fat, thin skin and inability to shiver or curl up
51
What heart defect is common in RDS?
PDA - increased pulse pressure - systolic impulses are audible
52
What are some common reasons for IUGR babies?
``` Smoking Pre-eclampsia Maternal drug or alcohol use Could be constitutionally small Genetic abnormalities HTN Cardiovascular or renal disease of mother Multiple pregnancy ```
53
What sort of growth pattern will you see in an IUGR baby?
Expect to see Head-Sparing effect in the baby - the head circumference will be normal while all other parameters are low (liver glycogen stores and sub-cut is low)
54
If the period of IUGR is prolonged what changes might you expect to see in the pattern of growth?
Might become symmetrically small (no head sparing) this is associated with chronic maternal conditions, genetic abnormalities in baby, congenital infection
55
What two measurements are most likely used to diagnose IUGR?
AC AND EFW (estimated fetal weight)
56
If the baby in utero is found to be growth restricted what investigations should be done?
USS Scan and fetal doppler Karyotyping Screening for CMV and toxoplasmosis
57
How often should testing be repeated in a woman who is found to have an IUGR baby and what should this testing involve?
USS and umbilical artery doppler every 2 weeks - do BFP (biophysical profile: AC, HC, FL, CRL etc.) Consider CTGs in these appointments as well (although should NOT be used alone) Assess amniotic fluid volume
58
At what age should we delivery IGUR babies?
If the IUGR is found before 32 weeks gestations then consider delivery at 32 weeks after giving steroids and assuming umbilical artery doppler is normal until then IF FOUND AFTER 32 weeks then consider delivery NO LATER than 37w
59
What immediate concerns do we have following the delivery of an IUGR baby?
Hypothermia - they need to be kept very warm. they will have thin skin and very little sub-cutaneous fat Hypoglycaemia - this is again because of their lack of fat and their use of their hepatic glycogen stores in utero Hypocalceamia Polycythaemia
60
What are some features of fetal alcohol syndrome?
``` Absent or small philtrum Small head Short palpebral fissures Epicanthal folds Mild ear abnormalities Flat nasal bridge Thin upper lip Small chin (micrognathia) ```
61
THE BABY CHECK: what questions should you ask before beginning?
Baby checks usually happen at 6-8 weeks... Is the baby smiling? Is the baby fixing and following? Is the baby starting to try support their own head? H+S - check the RED BOOK for the hearing assessment Ask mother questions about birth, neonatal period, pregnancy, birth weight (putting on since?)
62
What things do you need to look for on the head of the new born?
GENERAL INSPECTION (colour, crying, tone etc., birth marks, blue spots) 1. Feel for suture lines and fontanelles (bulging, sagging) 2. Measure the head circumference 3. Look in the baby's eyes for RED REFLEX 4. Check inside the baby's mouth for tongue tie, cleft palate and sucking reflex (GLOVED FINGER) 5. Check the face for any dysmorphic features
63
What things do we need to look for on the chest and torso during a baby check?
Look for breathing movements (symmetrical, any chest wall deformities) Check the cap refill centrally LISTEN to the heart and to the breathing (might want to do this earlier so baby doesn't cry) - Normal HR is 110-160 - listen for added sounds Finally feel the babies abdomen, can sometimes feel liver edge and tip of spleen but not massively ASK ABOUT MECONIUM AND POOING
64
What do you feel for in the groin and hips?
1. FEMORAL PULSES - are they present and equal 2. Check SCROTUM for testicles present - if not feel up and try and find then in inguinal region, if found them here can you manipulate them down 3. DDH - Barlow's (push back and down) and Ortolani's (pull back in) 4. Check ANUS for patency
65
What should you be looking for in the limbs and peripheries in the baby check?
1. Check for number of fingers and toes | 2. Check for tone in the limbs (moving regularly and symmetrically)
66
What should you check for on the spine and neck and how should you do this?
Lie the baby on its front (on your hand) and see if it is attempting to hold up its own head Also feel down the spine for any abnormalities, skin dimpling or lumps ***to further check for baby's tone can try pull them up to sitting by their hands to check for head lag?
67
What age would we expect babies to fully be able to support their own head?
3-4 months so some head lag on baby check is normal
68
In which babies is DDH more common?
``` Girls First born Breech FH Multiple pregnancy Oligohydramnios ``` If any of these risk factors USS at birth Pavlik harness to fix flex and slightly abduct
69
What are the two types of talipes?
TALIPES EQUINOVARUS - feet are hyper-introverted | TALIPES CALCANEOVALGUS - ankles are hyper flexed
70
What does talipes equinovarus appear like?
The feet are inverted and supinated and forefoot is adducted Often bilateral and calf muscle is thinner
71
What is talipes equinovarus associated with?
Oligohydramnios Male sex Spina bifida DDH
72
How is talipes equinovarus managed?
Bracing and casting immediately - PONSETTI METHOD | - Usually effective and if not consider surgery
73
What is talipes calcaneovalgus?
Foot is DORSIFLEXED and EVERTED
74
How should talipes calcaneovalgus be managed?
Usually self-limiting and has just occurred due to the shape of the uterus Sometimes mum can be given passive foot exercises to do Association with DDH
75
When do we class a pregnancy as being 'term'?
From 37 weeks onwards (although due dates are given at 40 weeks)
76
What is the average and minimal birth weight for a normal baby?
3.5kg is average | We are not concerned with any baby that is 2.5kg and above
77
What is the average length of a full term baby?
36.5-50cm
78
What might the skin of the newborn look like and what should we tell mum about this?
Dusky pink Can have lanugo (body hair, will go) Will be covered in VERNIX (almost creamy covering babies have) - NORMAL BABY ACNE is very common in the neonatal period - this is normal. Tell mum to just wash baby with soap and water and it will go Can have small, hard bumps called MILIA - these resolve themselves Baby's skin can also go PEELY - again this is normal
79
When would we normally expect the baby to have passed meconium and when does it become concerning if the baby hasn't yet passed it?
Normally would expect within 24 hours | Concerning if baby hasn't passed within 48 hours - consider bowel obstruction or meconium ileum (CF)
80
What changes does the fetal circulation undergo at birth?
Ductus venosus closes Ductus arteriosus closes Foramen ovale closes DA might not close for 6-8 weeks - takes a while for the arterial pressure to build up sufficiently to close this hole.
81
What condition might you consider when there is prolonged neonatal jaundice and hepatomegaly?
NEONATAL HEPATITIS
82
What causes neonatal hepatitis?
``` Congenital infection (TORCH) Inborn errors of metabolism Alpha-1 antitrypsin Galactoseamia Tyrosinaemia Errors of bile acid synthesis Progressive familial intra-hepatic cholestasis Cystic fibrosis ```
83
What is one of the differentials for prolonged jaundice in the newborn and what is a useful feature to differentiate between these two?
Biliary atresia - common cause Babies who have neonatal hepatitis will usually be a normal weight at birth however babies with biliary atresia will usually be low birth weight **also hepatomegaly will usually be present from birth
84
How is alpha-1 antitrypsin inherited and where around the body does it commonly affect?
Autosomal recessive | Affects the lungs as well as liver
85
What is the pathophysiology of alpha-1 anti-trypsin?
A1AT is a protease inhibitor and when it is deficient the protease is more active and starts to break down vital proteins around the body
86
Aside from the prolonged neonatal jaundice what is another key symptom of A1AT deficiency?
Bleeding - as the liver starts to fail clotting factors aren't produced as effectively Because bile isn't produced as well there is poor absorption of the fat-soluble vitamin K
87
What is one of the most concerning things to look for in the newborn from a mother that had diabetes mellitus during pregnancy?
HYPOGLYCAEMIA of the newborn - babies are used to being in very glucose rich environments and so have not adapted to managing normal concentrations of glucose
88
What other cases of hypoglycaemia in the neonatal period are there?
``` Sepsis Prematurity IGUR Hypothermia Maternal labetalol Inborn errors of metabolism Nesidoblastosis Beckwith-Weideman syndrome (overgrowth and cancer at birth) ```

Year 4 PAEDS (18 decks)

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