NEONATAL PROBLEMS Flashcards by Alex Kinsky

A baby is born at 39 weeks weighing 35kg. At 10 days the weight of the baby is still 35 kg. Should the doctor be worried?

No. All babies lose weight in the first week and full term babies should regain their birth weight by day 7-10. Pre-term babies should regain their birth weight by day 14.

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What is the best way to have a baby latched on for breast feeding?

Chin forward and head tilted back

The areola should be in the babies mouth

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What are the problems that a mother may face with regard to breast feeding?

Cracked nipples - related to problems with latching

Breast engorgement - full breasts. Can be alleviated by expression.

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A new mother presents to the GP on day 5 of her baby’s life worried that her baby is having loose stools. Should the doctor be worried?

No. This is called intestinal hurry and is common on day 4 or 5 when the supply of milk is plentiful. It is normal.

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What are the problems that can arise from only bottle feeding a baby?

Incorrect reconstitution - electrolyte abnormalities

Inadequate sterilization - gastroenteritis

Allergy to cow’s milk protein in formula

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What are the causes of neonatal vomiting? Try to separate them out using the surgical sieve.

Intestinal obstruction:

Duodenal atresia/stenosis
Malrotation with volvulus
Meconium ileus (cystic fibrosis)
Hirschsprung’s disease
Rectal atresia

Tracheo-oesaphageal fistula (associated with frothy mucoid vomit)

Infections:

Gastroenteritis
UTI
Septicaemia
Meningitis

Necrotizing enterocolitis (most often seen in preterms)

Raised intracranial pressure (bulging fontanelle)

Congenital adrenal hyperplasia (ambiguous genitalia in female infant)

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What would bile stained vomit in a newborn indicate?

Intestinal obstruction of some kind

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What might blood stained vomit in a newborn indicate?

Swallowed maternal blood

Trauma from a feeding tube

Haemorrhagic disease of the newborn

Vitamin K deficiency

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A baby is seen the morning after her birth late last night for her baby check. She is noticed to be slightly jaundiced. Should the doctor worry?

Yes. Jaundice within the first 24 hours of life is always pathological.

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What are the causes of jaundice in the first 24 hours of life?

Excess haemolysis:

Immune mediated - Rh or ABO incompatibility
Intrinsic red blood cell defects - G6PD, pyruvate kinase deficiency or hereditary spherocytosis

Congenital infections

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What are the causes of jaundice between 24 hours and 2 weeks of life?

Physiological jaundice

Breast milk jaundice

Infection (esp UTI)

Excess haemolysis

Bruising
Polycythaemia
Immune mediated
Red blood cell defects

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What are the causes of persistent unconjugated jaundice after 2 weeks of life?

Breast milk jaundice

Infections (esp UTI)

Excess haemolysis:

Bruising
Polycythaemia
Immune mediated
Red blood cell defects

Hypothyroidism

Galactosaemia

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What are the causes of persistent conjugated jaundice after 2 weeks of life?

Biliary atresia

Neonatal hepatitis

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What is physiological jaundice?

Jaundice caused by a combination of increased red cell breakdown (normal red blood life span is 70 days as opposed to 120 in adults) and immature hepatic enzymes.

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What investigations might you do in a baby that presents with prolonged (more than 2 weeks old) jaundice?

Measurement of conjugated fraction

FBC

Blood group - mother and baby

Direct antiglobulin test (DAT)

Urine culture

Thyroid function

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Which type of hyperbilirubinaemia is associated with dark urine and pale stool?

Conjugated - think biliary atresia or neonatal hepatitis

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What is the major complication of jaundice in neonates?

Kernicterus - unconjugated bilirubin deposited in the brain before the development of the blood-brain barrier.

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Where in the brain is most of the bilirubin deposited in kernicterus?

Cerebellum

Basal ganglia

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What are the clinical features of kernicterus?

Initially:

Lethargy
Rigidity
Eye rolling
Seizures

Long term:

Choreoathetoid cerebral palsy
Sensorineural deafness
Learning difficulties

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Other than high levels of bilirubin, what other factors increase the likelihood of a neonate developing kernicterus?

Infants gestational age: risk increases for preterm infants

Postnatal age: rick decreases with increasing postnatal age

Serum albumin: risk increases with hypoalbuminaemia

Coexistent asphyxia, acidosis or hypoglycaemia

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What is used to determine the bilirubin levels at which treatment should be initiated?

Consensus charts that take all the other risk factors into account

What are the treatment options for a neonate with hyperbilirubinaemia?

Phototherapy

Exchange transfusion

What is the phototherapy used in the treatment of neonatal jaundice, where levels start to threaten kernicterus?

Blue light of wavelength 450nm (not UV) converts bilirubin in the skin and superficial capillaries into harmless water soluble metabolites. Eyes need to be covered and additional fluids are given.

When would a neonate with hyperbilirubinaemia be treated with exchange transfusion as opposed to phototherapy?

If the bilirubin rises to levels considered dangerous despite phototherapy. Exchange is usually done via umbilical artery and vein catheters.

A mother brings in her 1 week old baby who is jaundiced. Blood tests reveal that her unconjugated bilirubin levels are at 800 micromols/L. Should the doctor be worried?

Yes. Despite the fact that this baby falls into the window when physiological jaundice is the most likely explanation for hyperbilirubinaemia, her levels of bilirubin are far too high for physiological jaundice and this baby needs treatment immediately to avoid complications. Physiological jaundice rarely leads to bilirubin levels above 350 micromols/L.

What are the signs of respiratory distress in a neonate?

``` Resp rate above 60 Subcostal or intercostal recession Nasal flaring Expiratory grunting Cyanosis ```

What is neonatal respiratory distress syndrome?

A disease seen mostly in preterm babies who have a deficiency of surfactant.

What are the treatment options for a baby born with respiratory distress syndrome?

Oxygen via a ventilator | Artificial surfactant

What is transient tachypnoea of the newborn?

A benign self-limiting condition believed to be caused by a delay in the normal reabsorption of lung fluid at birth. Usually resolves within 48 hours

What are the risk factors for transient tachypnoea of the newborn?

Caesarian section | Diabetic mothers

What will the X-ray of a baby with transient tachypnoea of the newborn show?

Streaky appearance with fluid in the horizontal fissure

Is meconium aspiration more common in term or preterm babies?

Term babies as preterm babies are unlikely to have passed meconium.

What proportion of term babies will have passed meconium before birth?

10%

What increases the risk of meconium aspiration?

Fetal distress eg hypoxic insult

What are the possible complications of meconium aspiration?

``` Bronchial obstruction and collapse Chemical pneumonitis Secondary infection Pneumothorax Pulmonary hypertension ```

How is meconium aspiration treated?

Suction as soon as the head is delivered Neonatal intubation for suction Oxygen

What are the risk factors for pneumonia in neonates?

Preterm Prolonged rupture of membrane (over 24 hours) Group B streptoccocal infection

What is persistent pulmonary hypertension of the newborn?

This is when pulmonary vascular resistance remains high after birth causing a right to left shunt at both atrial and ductal levels. There is therefore a severe cyanosis.

What are the causes of persistent pulmonary hypertension of the newborn?

Can be primary disorder, but more commonly a complication of: Perinatal asphyxia Meconium aspiration Severe sepsis Respiratory distress syndrome

How do you make a diagnosis of persistent pulmonary hypertension?

Suggested by differences in PaO2 on pre and post-ductal arterial blood gases (ABGs) and confirmed by echocardiography.

What is a diaphragmatic hernia?

A hole in the diaphragm allows the abdominal contents to herniate into the chest causing a restriction to breathing.

Which side are diaphragmatic hernias usually found on?

The left

How are most cases of diaphragmatic hernia diagnosed?

Ultrasound before birth

How do we treat diaphragmatic hernia?

Early intubation and nasogastric aspiration (to avoid inflation of the bowel) Surgical repair is then undertaken

If diaphragmatic hernia were not picked up pre-natally, what signs might indicate that it was this that was causing respiratory failure in a newborn?

Displaced apex beat to the right | Poor air entry on the left

What are the complications of diaphragmatic hernia?

Death | Pulmonary hypoplasia

What is chylothorax?

A rare cause of respiratory distress, due to accumulation of lymphatic fluid in the pleural cavity. Can be spontaneous (due to anomaly of lymphatic drainage) or iatrogenic from birth trauma or thoracotomy.

What is the differential diagnosis for a neonate with breathing difficulties?

``` Transient tachypnoea of the newborn Newborn respiratory distress syndrome (surfactant deficiency) Meconium aspiration Pneumonia Pneumothorax Persistent pulmonary hypertension of the newborn Diaphragmatic hernia Congenital malformation of the lung Chylothorax ```

What are the alternative names for the neonatal blood spot screening?

Guthrie test Heel prick test

At how many days of life is the neonatal blood spot screening test performed?

5-9 days

What are the 9 conditions screened for in the neonatal blood spot screening test?

Congenital hypothyroidism Cystic fibrosis Sickle cell disease Phenylketonuria (PKU) Medium chain acyl-CoA dehydrogenase deficiency (MCADD) Maple syrup urine disease (MSUD) Isovaleric acidaemia (IVA) Glutaric aciduria type 1 (GA1) Homocystinuria (pyridoxine unresponsive) (HCU)