Neonateology Flashcards

Question

Normal care after birth following leaving the delivery room?

Answer 1

Initiate breast feeding or bottle feeding as soon as the baby is alert enough The first bath is usually delayed until this baby is warm and stable. It can wait days without any issues. Newborn examination within 72 hours Blood spot test Newborn hearing test

Answer 2

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

Answer 3

This is a screening test for 9 congenital conditions. It is taken on day 5 (day 8 at the latest) after consent from the parent. A heel prick is used to provide drops of blood. The screening card requires four separate drops.

Answer 4

Ideally at day 5, by day 8 at the latest

Answer 5

Neonatal abstinence syndrome (NAS) refers to the withdrawal symptoms that happens in neonates of mothers that used substances in pregnancy. The symptoms and management is slightly different for each substance used in pregnancy. Mothers should be encouraged and supported with cutting back, and if possible stopping, substances that can affect the pregnancy.

Answer 6

Opiates Methadone Benzodiazepines Cocaine Amphetamines Nicotine or cannabis Alcohol SSRI antidepressants

Answer 7

Most opiates Diazepam SSRIs Alcohol

Answer 8

Most benzodiazepines other than diazepam Methadone

Answer 9

Irritability Increased tone High pitched cry Not settling Tremors Seizures

Answer 10

Yawning Sweating Unstable temperature and pyrexia Tachypnoea (fast breathing)

Answer 11

Poor feeding Regurgitation or vomiting Hypoglycaemia Loose stools with a sore nappy area

Answer 12

Testing for hepatitis B and C and HIV Safeguarding and social service involvement Safety-net advice for readmission if withdrawal signs and symptoms occur Follow up from paediatrics, social services, health visitors and the GP Support for the mother to stop using substances Check the suitability for breastfeeding in mothers with substance use

Answer 13

Mothers that are known to use substances should have an alert on their notes so that when they give birth the neonate can have extra monitoring and management of NAS. Babies are kept in hospital with monitoring on a NAS chart for at least 3 days (48 hours for SSRI antidepressants) to monitor for withdrawal symptoms. A urine sample can be collected from the neonate to test for substances. The neonate should be supported in a quiet and dim environment with gentle handling and comforting. Medical treatment options for moderate to severe symptoms are dependent on the substance. Neonates should be gradually weaned off oral treatment. SSRI withdrawal does not typically require or benefit from medical treatment.

Answer 14

Oral morphine sulphate for opiate withdrawal

Answer 15

Oral phenobarbitone for non-opiate withdrawal SSRI withdrawal does not typically require or benefit from medical treatment.

Answer 16

Fetal Alcohol Syndrome Congenital Rubella Syndrome Congenital Varicella Syndrome Congenital Cytomegalovirus Congenital Toxoplasmosis Congenital Zika Syndrome

Answer 17

Microcephaly (small head) Thin upper lip Smooth flat philtrum (the groove between the nose and upper lip) Short palpebral fissure (short horizontal distance from one side of the eye and the other) Learning disability Behavioural difficulties Hearing and vision problems Cerebral palsy

Answer 18

Congenital cataracts Congenital heart disease (PDA and pulmonary stenosis) Learning disability Hearing loss

Answer 19

First trimester

Answer 20

More severe cases in the mother, such as varicella pneumonitis, hepatitis or encephalitis Fetal varicella syndrome Severe neonatal varicella infection if mum is infected around delivery

Answer 21

Fetal growth restriction Microcephaly, hydrocephalus and learning disability Scars and significant skin changes following the dermatomes Limb hypoplasia (underdeveloped limbs) Cataracts and inflammation in the eye (chorioretinitis)

Answer 22

first 28 weeks of gestation.

Answer 23

Fetal growth restriction Microcephaly Hearing loss Vision loss Learning disability Seizures

Answer 24

Intracranial calcification Hydrocephalus Chorioretinitis

Answer 25

Infection with the Toxoplasma gondii parasite is usually asymptomatic. It is primarily spread by contamination with faeces from a cat that is a host of the parasite. When infection occurs during pregnancy it can lead to congenital toxoplasmosis. This risk is higher later in the pregnancy

Answer 26

Microcephaly Fetal growth restriction Other intracranial abnormalities, such as ventriculomegaly and cerebellar atrophy

Answer 27

Respiratory distress syndrome Hypothermia Hypoglycaemia Poor feeding Apnoea and bradycardia Neonatal jaundice Intraventricular haemorrhage Retinopathy of prematurity Necrotising enterocolitis Immature immune system and infection

Answer 28

Chronic lung disease of prematurity (CLDP) Learning and behavioural difficulties Susceptibility to infections, particularly respiratory tract infections Hearing and visual impairment Cerebral palsy

Answer 29

Sudden infant death syndrome (SIDS) is a sudden unexplained death in an infant. It is sometimes referred to as “cot death”. This usually occurs within the first six months of life.

Answer 30

Prematurity Low birth weight Smoking during pregnancy Male baby (only slightly increased risk)

Answer 31

Put the baby on their back when not directly supervised Keep their head uncovered Place their feet at the foot of the bed to prevent them sliding down and under the blanket Keep the cot clear of lots of toys and blankets Maintain a comfortable room temperature (16 – 20 ºC) Avoid smoking. Avoid handling the baby after smoking (smoke stays on clothes). Avoid co-sleeping, particularly on a sofa or chair If co-sleeping avoid alcohol, drugs, smoking, sleeping tablets or deep sleepers

Answer 32

The lullaby trust is a great charity to help support families affected. Bereavement services and bereavement counselling should be available for affected families.

Answer 33

Necrotising enterocolitis (NEC) is a disorder affecting premature neonates, where part of the bowel becomes necrotic. It is a life threatening emergency. Death of the bowel tissue can lead to bowel perforation. Bowel perforation leads to peritonitis and shock.

Answer 34

Very low birth weight or very premature Formula feeds (it is less common in babies fed by breast milk feeds) Respiratory distress and assisted ventilation Sepsis Patient ductus arteriosus and other congenital heart disease

Answer 35

Intolerance to feeds Vomiting, particularly with green bile Generally unwell Distended, tender abdomen Absent bowel sounds Blood in stools When perforation occurs there will be peritonitis and shock and the neonate will be severely unwell.

Answer 36

Full blood count for thrombocytopenia and neutropenia CRP for inflammation Capillary blood gas will show a metabolic acidosis Blood culture for sepsis

Answer 37

Abdominal xray is the investigation of choice for diagnosis in the supine position Bloods (FBC, CRP, blood culture) CBG

Answer 38

Neonates with suspected NEC need to be nil by mouth with IV fluids, total parenteral nutrition (TPN) and antibiotics to stabilise them. A nasogastric tube can be inserted to drain fluid and gas from the stomach and intestines. NEC is a surgical emergency and requires immediate referral to the neonatal surgical team. Some neonates will recover with medical treatment. In others, surgery may be required to remove the dead bowel tissue. Babies may be left with a temporary stoma if significant bowel is removed.

Answer 39

Perforation and peritonitis Sepsis Death Strictures Abscess formation Recurrence Long term stoma Short bowel syndrome after surgery

Answer 40

Apnoea are defined as periods where breathing stops spontaneously for more than 20 seconds, or shorter periods with oxygen desaturation or bradycardia. Apnoea can occur in neonates of all gestational ages. They are often accompanied by a period of bradycardia. Apnoea is very common in premature neonates. They occur in almost all babies less than 28 weeks gestation and the incidence decreases with increased gestational age. In term infants apnoea usually indicate underlying pathology.

Answer 41

Apnoea occur due to immaturity of the autonomic nervous system that controls respiration and heart rate. This system is more immature in premature neonates.

Answer 42

Infection Anaemia Airway obstruction (may be positional) CNS pathology, such as seizures or haemorrhage Gastro-oesophageal reflux Neonatal abstinence syndrome

Answer 43

Neonatal units attach apnoea monitors to premature babies. These make a sound when an apnoea is occurring. Tactile stimulation is used to prompt the baby to restart breathing. Intravenous caffeine can be used to prevent apnoea and bradycardia in babies with recurrent episodes. Episodes will settle as as the baby grows and develops.

Answer 44

Retinopathy of prematurity is a condition affecting preterm and low birth weight babies. It typically affects babies born before 32 weeks gestation. Abnormal development of the blood vessels in the retina can lead to scarring, retinal detachment and blindness. Treatment can prevent blindness, which is why screening is so important.

Answer 45

Babies born before 32 weeks

Answer 46

Retinal blood vessel development starts at around 16 weeks and is complete by 37 – 40 weeks gestation. The blood vessels grow from the middle of the retina to the outer area. This vessel formation is stimulated by hypoxia, which is a normal condition in the retina during pregnancy. When the retina is exposed to higher oxygen concentrations in a preterm baby, particularly with supplementary oxygen during medical care, the stimulant for normal blood vessel development is removed. When the hypoxic environment recurs, the retina responds by producing excessive blood vessels (neovascularisation), as well as scar tissue. These abnormal blood vessels may regress and leave the retina without a blood supply. The scar tissue may cause retinal detachment.

Answer 47

The retina is divided into three zones: Zone 1 includes the optic nerve and the macula Zone 2 is from the edge of zone 1 to the ora serrata, the pigmented border between the retina and ciliary body Zone 3 is outside the ora serrata The retinal areas are described as a clock face, for example “there is disease from 3 to 5 o’clock”. The areas of disease are described from stage 1 (slightly abnormal vessel growth) to stage 5 (complete retinal detachment). “Plus disease” describes additional findings, such as tortuous vessels and hazy vitreous humour.

Answer 48

Babies born before 32 weeks or under 1.5kg should be screened for ROP

Answer 49

30 – 31 weeks gestational age in babies born before 27 weeks 4 – 5 weeks of age in babies born after 27 weeks

Answer 50

Screening should happen at least every 2 weeks and can cease once the retinal vessels enter zone 3 (outside the ora serrata), usually at around 36 weeks gestation

Answer 51

All retinal areas need to be visualised. Screening involves monitoring the retinal vessels as they develop and looking for plus disease.

Answer 52

Treatment involves systematically targeting areas of the retina to stop new blood vessels developing. First line is transpupillary laser photocoagulation to halt and reverse neovascularisation. Other options are cryotherapy and injections of intravitreal VEGF inhibitors. Surgery may be required if retinal detachment occurs.

Answer 53

Hypoxia is central to neonatal resuscitation. Normal labour and birth leads to hypoxia. When contractions happen, the placenta is unable to carry out normal gaseous exchange, leading to hypoxia. Extended hypoxia will lead to anaerobic respiration and a subsequent drop in the fetal heart rate (bradycardia). Further hypoxia will lead to reduced consciousness and a drop in respiratory effort, in turn worsening hypoxia. Extended hypoxia to the brain leads to hypoxic-ischaemic encephalopathy (HIE), with potentially life-long consequences in the form of cerebral palsy.

Answer 54

Babies have a large surface area to weight ratio, and get cold very easily Babies are born wet, so they loose heat rapidly Babies that are born through meconium may have this in their mouth or airway

Answer 55

Warm the baby Calculate the APGAR Score Stimulate breathing Inflation breaths Chest compressions

Answer 56

This is done at 1, 5 and 10 minutes whilst resuscitation of the neonate continues This is used as an indicator of the progress over the first minutes after birth It helps guide neonatal resuscitation efforts

Answer 57

Get the baby dry as quickly as possible. Vigorous drying also helps stimulate breathing. Keep the baby warm with warm delivery rooms and management under a heat lamp Babies under 28 weeks are placed in a plastic bag while still wet and managed under a heat lamp

Answer 58

Simulate the baby to prompt breathing, for example by drying vigorously with a towel Place the baby’s head in a neutral position to keep airway open. A towel under the shoulders can help keep it neutral. If gasping or unable to breath, check for airway obstruction (i.e. meconium) and consider aspiration under direct visualisation

Answer 59

Inflation breaths are given when the neonate is gasping or not breathing despite adequate initial simulation.

Answer 60

- Two cycles of five inflation breaths (lasting 3 seconds each) can be given to stimulate breathing and heart rate - If there is no response and the heart rate is low, 30 seconds of ventilation breaths can be used - If there is still no response, chest compressions can be used, coordinated with the ventilation breaths

Answer 61

When performing inflation breaths, air should be used in term or near term babies, and a mix of air and oxygen should be used in pre-term babies. Oxygen saturations can be monitored throughout resuscitation if there are concerns about the breathing. Aim for a gradual rise in oxygen saturations, not exceeding 95%.

Answer 62

Start chest compressions if heart rate remains below 60 bpm despite resuscitation and inflation breaths (see protocol) Chest compressions are performed at a 3:1 ratio with ventilation breaths

Answer 63

Time is precious during neonatal resuscitation. Prolonged hypoxia increases the risk of hypoxic-ischaemic encephalopathy (HIE). In severe situations, IV drugs and intubation should be considered. Babies near or at term that have possible HIE may benefit from therapeutic hypothermia with active cooling.

Answer 64

The APGAR score is measured out of 10. The lowest score is 0 and the highest is 10. The included findings are: Appearance (skin colour) Pulse Grimmace (response to stimulation) Activity (muscle tone) Respiration

Answer 65

0: Blue / pale centrally 1: Blue extremities 2: Pink

Answer 66

0: Absent 1: < 100 2: > 100

Answer 67

0: No response 1: Little response 2: Good response

Answer 68

0: Floppy 1: Flexed arms and legs 2: Active

Answer 69

0: Absent 1: Slow / irregular 2: Strong / crying

Answer 70

Current guidelines from the resuscitation council UK state that uncompromised neonates should have a delay of at least one minute in the clamping of the umbilical cord following birth. Neonates that require neonatal resuscitation should have their umbilical cord clamped sooner to prevent delays in getting the baby to the resuscitation team. The priority will be resuscitation rather than delayed clamping.

Answer 71

After birth there is still a significant volume of fetal blood in the placenta. Delayed clamping of the umbilical cord provides time for this blood to enter the circulation of the baby. This is known as placental transfusion. Recent evidence indicates that in healthy babies, delaying cord clamping leads to improved haemoglobin, iron stores and blood pressure and a reduction in intraventricular haemorrhage and necrotising enterocolitis. The only apparent negative effect is an increase in neonatal jaundice, potentially requiring more phototherapy. Neonates that require neonatal resuscitation should have their umbilical cord clamped sooner to prevent delays in getting the baby to the resuscitation team. The priority will be resuscitation rather than delayed clamping.

Answer 72

Group B streptococcus (GBS) Escherichia coli (e. coli) Listeria Klebsiella Staphylococcus aureus

Answer 73

Vaginal GBS colonisation GBS sepsis in a previous baby Maternal sepsis, chorioamnionitis or fever > 38ºC Prematurity (less than 37 weeks) Early (premature) rupture of membrane Prolonged rupture of membranes (PROM)

Answer 74

Fever Reduced tone and activity Poor feeding Respiratory distress or apnoea Vomiting Tachycardia or bradycardia Hypoxia Jaundice within 24 hours Seizures Hypoglycaemia

Answer 75

Confirmed or suspected sepsis in the mother Signs of shock Seizures Term baby needing mechanical ventilation Respiratory distress starting more than 4 hours after birth Presumed sepsis in another baby in a multiple pregnancy

Answer 76

If there is one risk factor or clinical feature, monitor the observations and clinical condition for at least 12 hours If there are two or more risk factors or clinical feature of neonatal sepsis start antibiotics Antibiotics should be started if there is a single red flag Antibiotics should be given within 1 hour of making the decision to start them Blood cultures should be taken before antibiotics are given Check a baseline FBC and CRP Perform a lumbar puncture if infection is strongly suspected or there are features of meningitis (e.g. seizures)

Answer 77

benzylpenicillin and gentamycin

Answer 78

Check the CRP again at 24 hours and check the blood culture results at 36 hours: Consider stopping the antibiotics if the baby is clinically well, the blood cultures are negative 36 hours after taking them and both CRP results are less than 10. Check the CRP again at 5 days if they are still on treatment: Consider stopping antibiotics if the baby is clinically well, the lumbar puncture and blood cultures are negative and the CRP has returned to normal at 5 days. Consider performing a lumbar puncture if any of the CRP results are more than 10.

Answer 79

There is a high concentration of red blood cells in the fetus and neonate. These red blood cells are more fragile than normal red blood cells. The fetus and neonate also have less developed liver function. Fetal red blood cells break down more rapidly than normal red blood cells, releasing lots of bilirubin. Normally this bilirubin is excreted via the placenta, however at birth the foetus no longer has access to a placenta to excrete bilirubin. This leads to a normal rise in bilirubin shortly after birth, causing a mild yellowing of skin and sclera from 2 – 7 days of age. This usually resolves completely by 10 days. Most babies remain otherwise healthy and well.

Answer 80

This leads to a normal rise in bilirubin shortly after birth, causing a mild yellowing of skin and sclera from 2 – 7 days of age. This usually resolves completely by 10 days. Most babies remain otherwise healthy and well.

Answer 81

Haemolytic disease of the newborn ABO incompatibility Haemorrhage Intraventricular haemorrhage Cephalo-haematoma Polycythaemia Sepsis and disseminated intravascular coagulation G6PD deficiency

Answer 82

Prematurity Breast milk jaundice Neonatal cholestasis Extrahepatic biliary atresia Endocrine disorders (hypothyroid and hypopituitary) Gilbert syndrome

Answer 83

Jaundice in the first 24 hours of life is pathological. This needs urgent investigations and management. Neonatal sepsis is a common cause. Babies with jaundice within 24 hours of birth need treatment for sepsis if they have any other clinical features or risk factors.

Answer 84

In premature babies, the process of physiological jaundice is exaggerated due to the immature liver. This increases the risk of complications, particularly kernicterus. Kernicterus is brain damage due to high bilirubin levels. Bilirubin levels need to be carefully monitored in premature babies, as they may require treatment.

Answer 85

Components of breast milk inhibit the ability of the liver to process the bilirubin. Breastfed babies are more likely to become dehydrated if not feeding adequately. Inadequate breastfeeding may lead to slow passage of stools, increasing absorption of bilirubin in the intestines. Breastfeeding should still be encouraged, as the benefits of breastfeeding outweigh the risks of breast milk jaundice. Mothers may need extra support and advice to ensure adequate breastfeeding.

Answer 86

Haemolytic disease of the newborn is a cause of haemolysis (red blood cells breaking down) and jaundice in the neonate. It is caused by incompatibility between the rhesus antigens on the surface of the red blood cells of the mother and fetus. The rhesus antigens on the red blood cells vary between individual. This is different to the ABO blood group system. When a woman that is rhesus D negative (does not have the rhesus D antigen) becomes pregnant, we have to consider the possibility that her child will be rhesus D positive (has the rhesus D antigen). It is likely at some point in the pregnancy the blood from the baby will find a way into her bloodstream. When this happens, the baby’s red blood cells display the rhesus D antigen. The mother’s immune system will recognise this rhesus D antigen as foreign and produce antibodies to the rhesus D antigen. The mother has then become sensitised to rhesus D antigens. Usually, this sensitisation process does not cause problems during the first pregnancy (unless the sensitisation happens early on, such as during antepartum haemorrhage). During subsequent pregnancies, the mother’s anti-D antibodies can cross the placenta into the fetus. If that fetus is rhesus positive, these antibodies attach themselves to the red blood cells of the fetus and causes the immune system of the fetus to attack their own red blood cells. This leads to haemolysis, causing anaemia and high bilirubin levels.

Answer 87

More than 14 days in full term babies More than 21 days in premature babies

Answer 88

Biliary atresia Hypothyroidism G6PD deficiency

Answer 89

Full blood count and blood film for polycythaemia or anaemia Conjugated bilirubin: elevated levels indicate a hepatobiliary cause Blood type testing of mother and baby for ABO or rhesus incompatibility Direct Coombs Test (direct antiglobulin test) for haemolysis Thyroid function, particularly for hypothyroid Blood and urine cultures if infection is suspected. Suspected sepsis needs treatment with antibiotics. Glucose-6-phosphate-dehydrogenase (G6PD) levels for G6PD deficiency

Answer 90

In jaundiced neonates, total bilirubin levels are monitored and plotted on treatment threshold charts. These charts are specific for the gestational age of the baby at birth. The age of the baby is plotted on the x-axis and the total bilirubin level on the y-axis. If the total bilirubin reaches the threshold on the chart, they need to be commenced on treatment to lower their bilirubin level.

Answer 91

Phototherapy is usually adequate to correct neonatal jaundice. Extremely high levels may require an exchange transfusion. Exchange transfusions involve removing blood from the neonate and replacing it with donor blood.

Answer 92

Phototherapy converts unconjugated bilirubin into isomers that can be excreted in the bile and urine without requiring conjugation in the liver. Phototherapy involves removing clothing down to the nappy to expose the skin and eye patches to protect the eyes. Blue light is the best at breaking down bilirubin. A light-box shines blue light on the baby’s skin. Little or no UV light is used. Double phototherapy involves two light-boxes. Bilirubin is closely monitored during treatment. Once phototherapy is complete, a rebound bilirubin should be measured 12 – 18 hours after stopping to ensure the levels do not rise about the treatment threshold again.

Answer 93

Kernicterus is a type of brain damage caused by excessive bilirubin levels. It is the main reason we treat neonatal jaundice to keep bilirubin levels below certain thresholds. Bilirubin can cross the blood-brain barrier. Excessive bilirubin causes direct damage to the central nervous system. Kernicterus presents with a less responsive, floppy, drowsy baby with poor feeding. The damage to the nervous system is permeant, causing cerebral palsy, learning disability and deafness. Kernicterus is now rare due to effective treatment of jaundice.

Answer 94

Respiratory distress syndrome affects premature neonates, born before the lungs start producing adequate surfactant. Respiratory distress syndrome commonly occurs below 32 weeks.

Answer 95

Chest xray shows a “ground-glass” appearance.

Answer 96

Inadequate surfactant leads to high surface tension within alveoli. This leads to atelectasis (lung collapse), as it is more difficult for the alveoli and the lungs to expand. This leads to inadequate gaseous exchange, resulting in hypoxia, hypercapnia (high CO2) and respiratory distress.

Answer 97

Antenatal steroids (i.e. dexamethasone) given to mothers with suspected or confirmed preterm labour increases the production of surfactant and reduces the incidence and severity of respiratory distress syndrome in the baby. Premature neonates may need: Intubation and ventilation to fully assist breathing if the respiratory distress is severe Endotracheal surfactant, which is artificial surfactant delivered into the lungs via an endotracheal tube Continuous positive airway pressure (CPAP) via a nasal mask to help keep the lungs inflated whilst breathing Supplementary oxygen to maintain oxygen saturations between 91 and 95% in preterm neonates Support with breathing is gradually stepped down as the baby develops and is able to maintain their breathing, until they can support themselves in air.

Answer 98

Pneumothorax Infection Apnoea Intraventricular haemorrhage Pulmonary haemorrhage Necrotising enterocolitis

Answer 99

Chronic lung disease of prematurity Retinopathy of prematurity occurs more often and more severely in neonates with RDS Neurological, hearing and visual impairment

Answer 100

Hypoxic ischaemic encephalopathy (HIE) occurs in neonates as a result of hypoxia during birth. Hypoxia is a lack of oxygen, ischaemia refers to a restriction in blood flow to the brain and encephalopathy refers to malfunctioning of the brain. Some hypoxia is normal during birth, however prolonged or severe hypoxia leads to ischaemic brain damage. HIE can lead to permanent damage to the brain, causing cerebral palsy. Severe HIE can result in death.

Answer 101

When there are events that could lead to hypoxia during the perinatal or intrapartum period, acidosis (pH < 7) on the umbilical artery blood gas, poor Apgar scores, features of mild, moderate or severe HIE or evidence of multi organ failure.

Answer 102

Anything that leads to asphyxia (deprivation of oxygen) to the brain can cause HIE. For example: Maternal shock Intrapartum haemorrhage Prolapsed cord, causing compression of the cord during birth Nuchal cord, where the cord is wrapped around the neck of the baby

Answer 103

Poor feeding, generally irritability and hyper-alert Resolves within 24 hours Normal prognosis

Answer 104

Poor feeding, lethargic, hypotonic and seizures Can take weeks to resolve Up to 40% develop cerebral palsy

Answer 105

Reduced consciousness, apnoeas, flaccid and reduced or absent reflexes Up to 50% mortality Up to 90% develop cerebral palsy

Answer 106

Management will be coordinated by specialists in neonatology, on the neonatal unit. This involves supportive care with neonatal resuscitation and ongoing optimal ventilation, circulatory support, nutrition, acid base balance and treatment of seizures. Therapeutic hypothermia is an option in certain circumstances to help protect the brain from hypoxic injury. Children will need to be followed up by a paediatrician and the multidisciplinary team to assess their development and support any lasting disability.

Answer 107

Babies near or at term considered to have HIE can benefit from therapeutic hypothermia. Therapeutic hypothermia involves actively cooling the core temperature of the baby according to a strict protocol. The baby is transferred to neonatal ICU and actively cooled using cooling blankets and a cooling hat. The temperature is carefully monitored with a target of between 33 and 34°C, measured using a rectal probe. This is continued for 72 hours, after which the baby is gradually warmed to a normal temperature over 6 hours. The intention of therapeutic hypothermia is to reduce the inflammation and neurone loss after the acute hypoxic injury. It reduces the risk of cerebral palsy, developmental delay, learning disability, blindness and death.

Answer 108

Surface tension is the attraction of the molecules in a liquid to each other, pulling them together and minimising surface area.

Answer 109

Alveoli are the small sacs where gas collects and diffuses into the blood during inhalation. These are lined with fluid. The molecules of this fluid pull together due to surface tension, in turn pulling the walls of the alveoli towards each-other, attempting to collapse the space in the alveoli.

Answer 110

It contains proteins and fats. It sits on top of the water in the lungs. It has a hydrophilic side, that faces the water, and a hydrophobic side, that faces the air. The surfactant reduces the surface tension of the fluid in the lungs, essentially providing a barrier that reduces the water molecules tendency to pull towards each other. The result is that surfactant keeps the alveoli inflated and maximises the surface area of the alveoli. This reduces the force needed to expand the alveoli and therefore the lungs during inspiration. This is known as compliance. Therefore, surfactant increases lung compliance. Additionally, as an alveolus expands, the surfactant becomes more thinly spread and therefore the surface tension increases, making it more difficult to expand that alveolus further. This stops one alveolus expanding massively whilst another alveolus only expands a little. Therefore, surfactant promotes equal expansion of all alveoli during inspiration.

Answer 111

Surfactant is a fluid produced by type II alveolar cells. Type II alveolar cells become mature enough to start producing surfactant between 24 and 34 weeks gestation. Therefore, pre-term babies have problems associated with reduced pulmonary surfactant.

Answer 112

During birth the thorax is squeezed as the body passes through the vagina, helping to clear fluid from the lungs. Adrenalin and cortisol are released in response to the stress of labour, stimulating respiratory effort. The first breaths the baby takes expands the alveoli, decreasing the pulmonary vascular resistance. The decrease in pulmonary vascular resistance causes a fall in pressure in the right atrium. At this point the left atrial pressure is greater than the right atrial pressure, which squashes the atrial septum and causes functional closure of the foramen ovale. The foramen ovale then structurally closes and becomes the fossa ovalis. Prostaglandins are required to keep the ductus arteriosus open. Increased blood oxygenation causes a drop in circulating prostaglandins. This causes closure of the ductus arteriosus, which becomes the ligamentum arteriosum. Immediately after birth the ductus venosus stops functioning because the umbilical cord is clamped and there is no blood flow in the umbilical veins. The ductus venosus structurally closes a few days later and becomes the ligamentum venosum.

Answer 113

The examination is performed within the first 72 hours after birth. It is repeated at 6 – 8 weeks by their GP. The initial check can be performed by a trained midwife or paediatric doctor. For home births the GP may visit to perform the baby check.

Answer 114

Has the baby passed meconium? Is the baby feeding ok? Is there a family history of congenital heart, eye or hips problems?

Answer 115

Babies should have their pre-ductal and post-ductal oxygen saturations checked. This measures the oxygen level before and after the ductus arteriosus. Normal saturations are 96% or above. There should not be more than a 2% difference between the pre-ductal and post-ductal saturations. Abnormal saturations require further investigation and potentially admission to the neonatal unit.

Answer 116

The ductus arteriosus is located along the arch of the aorta and connects the aorta with the pulmonary artery.

Answer 117

It normally stops functioning within 1 – 3 days of birth.

Answer 118

It allows blood from the deoxygenated right sided circulation before the lungs to mix with the oxygenated left sided circulation after the lungs.

Answer 119

They rely on the mixing of blood across the ductus arteriosus. When the ductus arteriosus closes there can be a rapid deterioration in symptoms. These duct-dependent conditions may be picked up by measuring the difference in pre-ductal and post-ductal saturations.

Answer 120

Pre-ductal saturations are measured in the baby’s right hand. The right hand receives blood from the right subclavian artery, a branch of the brachiocephalic artery, which branches from the aorta before the ductus arteriosus. Post-ductal saturations are measured in either foot. The feet receive blood traveling from the descending aorta, which occurs after the ductus arteriosus.

Answer 121

General appearance Head Shoulders and arms Chest Abdomen Genitals Legs Back Reflexes Note any skin findings

Answer 122

Colour (pink is good) Tone Cry

Answer 123

General appearance: size, shape, dysmorphology, caput succedaneum, cephalohaematoma and any facial injury Head circumference: known as the occipital frontal circumference (OCP) Anterior and posterior fontanelles Sutures: overlapping sutures are common and usually resolve as the baby grows Ears: skin tags, low set ears and asymmetry Eyes: slight squints are normal, epicanthic folds can indicate Down’s, purulent discharge could indicate infection Red reflex using an ophthalmoscope: check for symmetry. It is often more pale in darker skinned babies. It is absent with congenital cataracts and retinoblastoma. Mouth: cleft lip or tongue tie Put your little finger in their mouth to check the suckling reflect and feel the palate all the way back, checking for a cleft palate.

Answer 124

Shoulder symmetry: check for a clavicle fracture Arm movements: check for an Erbs palsy Brachial pulses Radial pulses Palmar creases: a single palmar crease is associated with Down’s, but can be normal Digits: check the number of digits and if the fingers are straight or curved (clinodactyly) Use a sats probe on the right wrist for a pre-ductal reading

Answer 125

Oxygen saturations in the right wrist and a feet: 95% and above is normal Observe breathing: look for respiration distress, symmetry and listen for stridor Heart sounds: listen for murmurs, heart sounds, heart rate and identify which side the heart is on heart Breath sounds: listen for symmetry, good air entry and added sounds

Answer 126

Observe the shape: a concave abdomen may indicate diaphragmatic hernia with abdominal contents in the chest Umbilical stump: look for discharge, infection and a periumbilical hernia Palpate for organomegaly, hernias or masses

Answer 127

Observe for the sex, ambiguity and any obvious abnormalities Palpate testes and scrotum: check both are present and descended, check for hernias or hydroceles Inspect the penis for hypospadias, epispadias and urination Inspect the anus to check if it is patent Ask about meconium and whether the baby has opened the bowel

Answer 128

Observe the legs and hips for equal movements, skin creases, tone and talipes Barlows and Ortolani manoeuvres: check for clunking, clicking and dislocation of the hips Count the toes

Answer 129

Inspect and palpate the spine: look for curvature, spina bifida and a pilonidal sinus

Answer 130

Moro reflex: when rapidly tipped backwards the arms and legs will extend Suckling reflex: placing a finger in the mouth will prompt them to suck Rooting reflex: tickling the cheek will cause them to turn towards the stimulus Grasp reflex: placing a finger in the palm will cause them to grasp Stepping reflex: when held upright and the feet touch a surface they will make a stepping motion

Answer 131

Haemangiomas Port wine stains Mongolian blue spot Cradle cap Desquamation Erythema toxicum Milia Acne Naevus simplex (“stork bite”) Moles Transient pustular melanosis

Answer 132

Talipes, also known as clubfoot, is where the ankles are in a supinated position, rolled inwards. It can be positional or structural.

Answer 133

Positional talipes is where the muscles are slightly tight around the ankle but the bones are unaffected. The foot can still be moved into the normal position. This requires referral to a physiotherapist for some simple exercises and will resolve with time. Structural talipes involves the bones of the foot and ankle and requires referral to an orthopaedic surgeon.

Answer 134

Undescended testes require monitoring and referral to a urologist.

Answer 135

Skin findings generally do not require any action. Many will fade with time. Haemangiomas near the eyes, mouth or affecting the airway may require referral for treatment with beta blockers (i.e. propranolol). Otherwise they can be monitored and usually resolve with time. Port wine stains are pink patches of skin, often on the face, caused by abnormalities affecting the capillaries. They don’t fade with time and typically turn a darker red or purple colour. Rarely they can be related to a condition called Sturge-Weber syndrome, where there can be visual impairment, learning difficulties, headaches, epilepsy and glaucoma.

Answer 136

Clicky or clunky hips require referral for a hip ultrasound to rule out developmental dysplasia of the hips.

Answer 137

Soft systolic murmurs of grade 2 or less in otherwise healthy well neonates may be monitored, as these often resolve after 24 – 48 hours. This may be caused by a patent foramen ovale that closes shortly after birth. Any suspicion of heart failure or congenital heart disease requires referral to cardiology for an ECG and echocardiogram. If they are unwell, they require admission to the neonatal unit and immediate management.

Answer 138

Discuss any abnormalities with a senior Action any abnormalities (e.g. ultrasound request for clicks hips) Document the examination findings on the newborn and infant physical examination (NIPE) computer system and in the baby’s red book Explain, reassure and answer any questions with the parents Arrange referrals and followup if required

Answer 139

respirstory distress greenish-tinged skin intercostal recession poor cry

Answer 140

3:1 is the recommended ratio of chest compressions to ventilation breaths for neonatal resuscitation.

Answer 141

10 minuites

Answer 142

Birth complications: hypoxia, breech, should dystocia Gestation: premature (37 weeks) or late (42 weeks) Birth weight Growth and weight percentiles Growth rate Milestones +/- regression Vaccinations Screening tests + results Examinations + results Any hospital stays? Any problems at or around birth e.g. jaundice, sepsis, stays on NICU, ARDs Known or family history of genetic syndromes Multiple births?

Answer 143

1 and 5 mins following birth

Answer 144

Newborn - otoacoustic emission

Answer 145

Retinal haemorrhages, subdural haematoma, and encephalopathy.

Answer 146

intestinal atresia

Answer 147

48-72 hrs Groub B strep (40%) E. Coli (20%)

Answer 148

After 72 hrs Coagulase negative staph (majority) Enterococcus Staph aureus Klebsiella

Answer 149

Infection aquired in-utero - haematogenous or transplacental

Answer 150

Infection acquired during or after delivery (ascending infection from vaginal pathogens or enviromental source)

Answer 151

Carriage is variable, up to 35% of women are colonized Not all colonized women will come back positive The density of infant colonization determines the risk of early-onset invasive disease Only a small number of colonized babies will develop invasive disease, however they will present in the early hours of life

Answer 152

Prelabour +/- prolonged (>18 hours) rupture of membranes Prematurity, preterm birth following spontaneous labour before 37 weeks gestation Maternal infection (during labour e.g. chorioamnionitis, GBS colonisation) - intrapartum fever higher than 38 degrees if there is a suspected or confirmed bacteria; infection Suspected or confirmed infection in another baby in the case multiple pregnancy Low birth weight Invasive procedures (iv catheters, intubation) Maternal GBS colonisation Apnoea Signs of shock Need for CPR or mechanical ventilation Seizures

Neonateology Flashcards

(177 cards)