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Neonatal Medicine Flashcards

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1
Q

Neonatal care

A

Level 1: special care
Level 2: short-term intensive care
Level 3: long term intensive care

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2
Q

Causes of hypoxic-ischaemic encephalopathy

A

Failure of gas exchange accross the placenta
Interruption of umbilical blood flow
Inadequate maternal placental perfusion
Compromised fetus
Failure of cardiopulmonary adaptation at birth

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3
Q

Clinical manifestation of hypoxic ischaemic encephalopathy

A

Mild: irritable infant, responds excessively to stimulation, staring of eyes, hyperventilation, hypertonia, impaired feeding
Moderate: marked abnormalities of movement, hypotonic, cannot feed, may have seizures
Severe: no normal spontaneous movement or response to pain, tone in limbs, fluctuation between hypotonia and hypertonia, prolonged seizures, multi-organ failure

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4
Q

Mx hypoxic ischaemic encephalopathy

A

Respiratoy support
Anticonvulsants for seizures
Fluid restriction: transient renal impairment
Inotrope and volume support of hypotension
Monitoring of hypoglycaemia and electrolyte imbalance
Cooling effective if initiated within 6h

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5
Q

Prognosis hypoxic ischaemic encephalopathy

A

Complete recovery in mild hypoxic iscahemic encephalopathy
Good prognosis if mostly recovered by 2w
Mortality severe HIE ~ 40%

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6
Q

Features suggestive of birth asphyxia

A

Evidence of severe hypoxia antenatally, during labour/delivery
Resuscitation needed at birth
Features of encephalopathy
Hypoxic damage to other organs
No other prenatal or postnatal cause identified

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7
Q

Multi-organ dysfunction in hypoxic iscahemic encephalopathy

A 
Abnormal neurological signs
Seizures
PPH of the newborn
hypotension
hypoglycaemia
hypocalcaemia
hyponatraemia
Renal failure
DIC
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8
Q

Soft tissue injury during birth

A

caput succedaneum: bruising and odema of presenting part extends beyond margins of skull bones
Cephalhaematoma: bleeding below periosteum, confined by skull sutures
Chignon: odema and bruising from ventouse
Abrasions: scalp electrodes/accidental incision during Csection
Subaponeurotic haemorrhage: diffuse boggy swelling of the scalp, blood loss can be significant

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9
Q

Features Brachial nerve plexus palsy during delivery

A

Traction to the brachial plexus nerve roots
-breech delivery
-shoulder dystocia
Upper nerve C5/6 causes Erb’s palsy

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10
Q

Features facial palsy during delivery

A

Compression against mothers ischial spine/ forceps pressure
Facial weakness on crying
Eye remains open
Usually transient

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11
Q

Cx prematurity

A 
Respiratory distress syndrome
Pneumothorax
Apnoea and bradycardia
Hypotension
Patent ductus arteriosus
Temperature control
Hypoglycaemia
Hypocalcaemia
Electrolyte imbalance
Osteopenia of prematurity
Nutrition
Infection
Jaundic
Intraventricular haemorrhage
Periventricular leukomalacia
Necrotixing enterocolitis
Retinopathy of prematurity
Anaemia of prematurity
Iatrogenic
Bronchopulmonary dysplasia
Inguinal hernias
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12
Q

Fractures during delivery

A 
Clavicle
-typically shoulder dystocia
-excellent prognosis
-callus lump at clavicle after several weeks
Humerus/femur
-occurs at breech deliveries or dystocia
-heal rapidly with immobilisation
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13
Q

Features respiratory distress syndrome

A

At delivery or within 4h of birth
Tachypnoea >60 breaths/min
Laboured breathing with chest wall recession and nasal flaring
Expiratory grunting (attempt to produce positive airway pressure)
Cyanosis

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14
Q

Ix respiratory distress syndrome

A

Typical chest Xray: diffuse granular or ground glass appearance of the lungs and air bronchogram

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15
Q

Mx respiratory distress syndrome

A

Corticosteroids prior to delivery in at risk patients reduces incidence
Oxygen, assisted ventilation, exogenous surfactant via endotracheal tube

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16
Q

Cx respiratory distress syndrome

A 
pneumothorax
lobar collapse
bronchopulmonary dysplasia
chronic lung disease of prematurity
Cor pulmonale
intraventricular haemorrhage
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17
Q

Apnoea and bradycardia in premature infants

A

Common until 32w gestational age
Bradycardia associated with apnoea >20-30s
Usually immaturity of centrl respiratory control
Breathing restarts with gentle physical stimulation/ caffeine stimulation

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18
Q

Factors predisposing preterm infants to hypothermia

A

large SA:V
thin heat permable skin and transepidermal water loss
Little subcut fat
often nursed naked
Cannot curl up or shiver to conserve or generate heat

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19
Q

Prevention of heat loss in newborns

A 
Raise temp of ambient air in incubator
Clothe including head covering
Double walls of incubator
Dry and wrap at birth
Nurse on heated mattress
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20
Q

Features patent ductus arteriosus

A 
Common in preterm infants, esp in RDS
Bounding pulse
Increased pulse pressure
Prominent precordial impulse
Systolic murmur
Signs of heart failure
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21
Q

Mx patent ductus arteriosus

A

prostaglandin synthetase inhibitor .e.g. indomethacin or ibuprofen
Surgical ligation

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22
Q

Features septicaemia

A

Risk factors: PROM, GBS positive mother, maternal temperature
Typically bradycardia, desaturations
Complete septic screen including blood culture, urine culture, lumbar puncture, CRP and leucocyte count
Immediate broad spectrum Abx to symptomatic and at risk neonates

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23
Q

Features Nectrotising enterocolitis

A

Risk increases with increasing prematurity
Common in formula feeding
Presents in the first few weeks, stops tolerating feeds, bile stained vomit, abdo distention, fresh blood in stools

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24
Q

Xray features necrotising enterocolitis

A

dilated bowel loops, bowel wall edema, pneumatosis intesinalis, portal venous gas, Rigler sign, football sign

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25
Mx Necrotising enterocolitis
Urgent IV fluid resuscitation and maintenance, parenteral feeding, broad spectrum Abx .e.g. Penicillin, metronidazole and gentamicin Possible development of structures/adhesions, malabsorption in bowel resection
26
Risk factors Respiratory distress syndrome
``` Male Diabetic mothers C section 2nd born twin Infants <28w ```
27
Features pneumothorax newborn
More common in ventilation hence associated with RDS Increased oxygen requirement and reduced breath sounds unilateral Transillumination of the chest wall by bright optic light source Urgent decompression of tension pneumothorax Avoidance by low pressure ventilation
28
Intraventricular haemorrhage features
Haemorrhage in 20% of low birthweight infants Typically in germinal matrix above caudate nucleus: fragile network of blood vessels Usually occurs within the first 72 hours Associated with RDS, perinatal asphyxia Most severe form causes hemiplegia Impairing of CSF daining: separation cranial sutures, rapidly increasing head circumference, tense fontanelle
29
Mx Intraventricular haemorrhage
Symptomatic relief by CSF removal via LP or ventricular tap | Ventriculoperitoneal shunt can be used for CSF drainage
30
Newborn retinopathy
Developing blood vessels and the junction of vascularised and non-vascularised retina May progress to retinal detachment, fibrosis and blindness Associated with uncontrolled use of oxygen
31
Features bronchopulmonary dysplasia
Infant with oxygen requirement at 36 weeks Lung damage due to delay in maturation Chest xray shows widespread areas of opacification with cystic changes Progression of RDS to pulmonary interstitial emphysema
32
Mx bronchopulmonary dysplasia
Nutritional optimisation, oxygen supplementation and intubation as required Corticosteroids and diuretics may improve lung function
33
Newborn hypoglycaemia
Onset in first 24 hours Typically IUGR, prematurity, diabetic mothers, large for dates, hypothermic, polycythaemia, illness Optimal blood glucose 2.6mmol/L Lethargy, poor feeding, jitteriness, seizures, apnoea Abnormal blood glucose: confirmed by lab
34
Mx neontala hypoglycaemia
Good feeding is sufficient to treat hypoglycemia IV dextrose if necessary Rarely diazoxide is used to suppress insulin
35
Features Jaundiced baby
Deposition of bilirubin in the skin: common in newborns. Typically starts with face and progresses to limbs
36
Causes Jaundice <24hr
``` Rhesus incompatibility ABO incompatibility G6PD deficiency Spherocytosis Pyruvate Kinase Deficiency Congenital Infection ```
37
Causes Jaundice 24h-2w
``` Physiological Breast milk jaundice Infection Haemolysis (late presentation) Bruising Polycythaemia Crigler-Najjar Syndrome ```
38
Causes Jaundice >2w
``` Physiological/Breast milk Jaundice Infections especially UTIs Hypothyroidism Haemolytic anaemias High GI obstruction Neonatal hepatitis Bile duct obstruction ```
39
Ix Jaundice
transcutaneous bilirubin, serum bilirubin if within 50 of treatment thresholds
40
Mx Neonatal Jaundice
dual emission phototherapy (450nm) with a bilirubin above 350 (plateau by day 3), and rebound bilirubin after 2 weeks. Possible exchange transfusion if phototherapy unsuccessful replacing twice the neonatal blood volume
41
Cx Neonatal Jaundice
kernicterus (basal ganglia damage from excess bilirubin crossing BBB causing encephalitis)
42
Features physiological jaundice
Inefficient bilirubin metabolism: common High Hb concentration at birth, shorter RBC life span and inefficiency of metabolism all contribute to slower breakdown Mild, presents at day 2-3 self resolves within first week
43
Features neonatal hepatitis
Bruising, poor weight gain, dark urine, pale stools | Check maternal hepatitis status
44
Features biliary atresia
Presents after 2-3 weeks Dark urine, pale stools Surgical intervention immediately Late recognition can result in need for transplantation
45
Features haemolytic ABO disease newborn
``` Presents within 12-72 hours AB IgM antibodies do not cross the placental but IgG can Group OF mothers with A/B/AB babies Hepatosplenomegaly absent Coombs test positive ```
46
Features congenital hypothyroidism
Coarse facial features, hoarse cry, dry umbilicus | Screening at day 7 via heel prick, serum TSH and T4
47
Features rhesus haemolytic disease
Affected infants usually identified antenatally Severe presentation of anaemia, hydrops, hepatosplenomegaly Antibiotics typically to rhesus D, but may develop against Kell and Duffy blood groups
48
Features G6PD deficiency
X linked recessive condition Typically mediterrean,. Middle East and African populations Mainly affects males Intravascular haemolysis, splenomegaly, gallstones Heinz bodies on blood film
49
Mx G6PD deficiency
Avoidance of specific drugs which precipitate jaundice: Anti-malarias .e.g. Primaquine, ciprofloxacin, sulph-drug groups .e.g. Sulphonamides, sulfasalazine, sulfonylureas Safe medications: penicillins, cephalosporins, macrolides, tetracyclines, trimethoprim
50
Features spherocytosis
Autosomal Dominant affecting shape of rbc Diagnosis by spherocytes on blood film: round, lack of central pallor Northern European populations Extravascular haemolysis Haemolytic crisis precipitated by infection Osmotic fragility test is diagnostic
51
Features polycythaemia
Venous haematocrit >0.65 | Babies typically have a high packed cell volume
52
Features Crigler Najjar
Autosomal Recessive Absolute deficiency of UDP-glucuronosyl (type 1) Type 1 do not survive to adulthood Type 2 may improve with phenobarbital
53
dDx breathing difficulty in the newborn
``` Respiratory distress syndrome Transient tachypnoea of the newborn Meconium aspiration Birth Asphyxia Diaphragmatic hernia Laryngomalacia Tracheoesophageal fistula Pneumonia Persistent pulmonary hypertension of the newborn ```
54
Features transient tachypnoea of the newborn
Most common cause of respiratory distress in term babies Delay in clearance of fluid in lungs: C section greater incident ? fluid not squeezed out Respiratory distress and cyanosis Self resolves within a few days
55
Chest Xray transient tachypnoea of the newborn
hyperinflation of lungs, fluid in horizontal fissure, cardiomegaly and prominent perihilar markings
56
Features meconium aspiration
Passage of meconium before birth, typically in post-dates | Typically causes a chemical pneumonitis
57
Risk factors meconium aspiration
post-dates, maternal hypertension, preeclampsia, chorioamnionitis, smoking, substance misuse
58
Chest Xray meconium aspiration
over inflation and heterogeneous opacification (collapse and consolidation)
59
Mx Meconium aspiration
Mechanical ventilation often required | Inotropic support of blood pressure and inhaled NO
60
Features diaphragmatic hernia
Usually diagnosed on antenatal screening Failure to respond to resuscitation or respiratory distress Displaced apex beat and heart sounds to right side of chest Poor air entry on left side
61
Mx diaphragmatic hernia
NG tube to drain and prevent distention | Surgical repair
62
Cx diaphragmatic hernia
Compression can prevent lung development causing hypoplastic lungs
63
Newborn pneumonia causative organisms
Gram negative bacilli (E.coli, klebsiella, pseudomonas), group B strep and staphylococcus
64
Features persistent pulmonary hypertension of the newborn
Acute neonatal emergence Persistence of intracardiac shunts due to high pulmonary vascular resistance All cases before 72 hours Usually associated with birth asphyxia, meconium aspiration, septicaemia, RDS Worsening cyanosis, hypoxia and tachypnoea Echocardiogram includes cardiac pathology and shows increased pulmonary pressures and tricuspid regurgitation
65
Mx PPH of newborn
Requires mechanical ventilation and respiratory support Inhaled NO and potent vasodilators Systemic BP is kept high to prevent right lieft shunting
66
MX neonatal conjunctivitis
Common in neonatal period Saline cleaning allows for spontaneous resolution Purulent discharge, infection, swelling of eyelid suggest gonococcal infection- third gen cephalosporin Chlamydia present at 1-2 weeks- treated with oral erythromycin for 2 weeks
67
Features Early onset neonatal infection
Illness within 48 hours Usually vertical transmission from mother Prophylactic treatment if mother exhibiting signs of infection, GBS positive, PROM, prematurity Fever and temperature instability, irritability, poor feeding, panoea, bradycardic, respiratory distress, jaundice, neutropenia, hypoglycemia, lethargy, seizures Usually GBS, rarely listeria, klebsiella, pseudomonas
68
Mx Early onset infection in newborn
CRP may take 12-24 hours to increase: prophylactic antibiotics can be stopped if no CRP rise Blood culture and inflammatory markers: consider LP Broad Spectrum Abx .e.g. Benzylpenicillin + gentamicin
69
Features Late onset infection in newborn
Likely environmental agent Onset after 48 hours Coagulase negative staph most common
70
Mx late onset infection in newborn
Initially flucloxacillin and gentamicin | Neuropenum and vancomycin may be required if initial treatment resistance
71
Features umbilical injection
Usually umbilicus dries and separates spontaneously Redness and inflammation suggests infection hence antibiotics are used Granulous tissue should be ligated or treated with silver nitrate

Paediatrics (22 decks)

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