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Neonatology Flashcards

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1
Q

early onset neonatal sepsis definition

A

sepsis occurring within the first 48-72 hours of life

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2
Q

prevalence EONS

A

0.9/1000 live births and 9/1000 admissions in uk…rare
mortality rate 16%

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3
Q

most likely cause of severe neonatal infection

A

group B strep
others - e.coli, coagulase neg strep, haem influenzae and listeria monocytogenes

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4
Q

EONS pathophysiology

A

ascending infection in the mother with chorioamnionitis, perinatally via direct contact in birth canal and haematogenous spread

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5
Q

clinical features - early and late in EONS

A

early - resp distress, pneumonia, sepsis
later - sepsis and/or meningitis

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6
Q

chorioamnionitis in mothers prevention

A

can give intrapartum abx

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7
Q

risk factors for infection EONS

A

Invasive group B streptococcal infection in a previous baby
Maternal group B streptococcal colonisation, bacteriuria or infection in the current pregnancy
Prelabour rupture of membranes
Preterm birth following spontaneous labour (before 37 weeks’ gestation)
Suspected or confirmed rupture of membranes for more than 18 hours in a preterm birth
Intrapartum fever higher than 38°C, or confirmed or suspected chorioamnionitis

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8
Q

red flags for EONS

A

parental abx given to woman at any point during labour or in 24 hr period before and after birth
infection in another baby in case of multiple pregnacny

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9
Q

red flags clinical features EONS

A

resp distress starting more than 4 hours after birth
seizures
need for mechanical ventilation in a term baby
signs of shock

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10
Q

EONS ddx

A

transient tachypnoea of newborn
ARDS
meconium aspiration

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11
Q

EONS investigations

A

FBC
CRP
blood cultures
LP

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12
Q

EONS management

A

IV benzylpenicillin with gentamicin for 7-10 days if blood cultures positive or 14 days if CSF also positive
consider stopping at 36 hrs if think infection not present

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13
Q

prognosis EONS

A

mortality 2-4%
higher if low birth weight or pre term

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14
Q

prevalence neonatal jaundice

A

60% of term infants and 80% of preterm infants
unconjugated - can be physiology or pathological or conjugated which is always pathological

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15
Q

physiological jaundice

A

increased red cell breakdown - in utero fetus has high conc of Hb …broken down
immature liver - not process high billirubin
resolves by day 10
can progress to pathological if baby premature or increased cell breakdown from bruising

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16
Q

pathological jaundice

A

haemolytic disease - of newborn, ABO incompatibility, G6PD deficiency, spherocytosis
bilirubin above phototherapy threshold - likely dehhydrated aor due to bruising etc
unwell neonate - infection
prolonged jaundice - >14 days in infants, >21 days in preterm

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17
Q

prolonged jaundice causes

A

Infection
Metabolic: Hypothyroid/pituitarism, galactosaemia
Breast milk jaundice: well baby, resolves between 1.5-4 months
GI: biliary atresia, choledhocal cyst

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18
Q

risk factors for pathological jaundice

A

Prematurity, low birth weight, small for dates
Previous sibling required phototherapy
Exclusively breast fed
Jaundice <24 hours
Infant of diabetic mother

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19
Q

clinical presentation jaundice

A

colour of baby
drowsy - not waking for feeds
neuro - altered muscle tone, seizures
other - signs of infection, poor UO, abdo mass, stool remains black/not chnaging colour

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20
Q

jaundice investigations billirubin

A

Transcutaneous bilirubinometer (TCB) can be used in >35/40 gestation and >24 hours old for first measurement. TCB can be used for all subsequent measurements, providing the level remains <250 µmol/L and the child has not required treatment
Serum bilirubin to be measured if <35/40 gestation, <24 hours old or TCB >250 µmol/L

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21
Q

jaundice investigations other

A

serum billirubin
blood group and DCT
FBC
UE
infection screen
glucose 6 P dehydrogenase
LFT
TFT

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22
Q

management billirubin

A

phototherapy - look at charts
ex[ressed materal milk
consider NG and IV fluids if feeding poor
exchange transfusion - with donated blood or plasma via umbilical artery or vein
IV immunoglobulin

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23
Q

complications neonatal jaundice

A

Kernicterus, billirubin-induced brain dysfunction, can result from neonatal jaundice. Bilirubin is neurotoxic and at high levels can accumulate in the CNS gray matter causing irreversible neurological damage.

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24
Q

meconium aspiration syndrome definition

A

spectrum of disorders…various degrees of resp distress due to the aspiration of meconium stained amniotic fluid
mostly during birth, can occur antenatally

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25
what is meconium
dark green, sticky and lumpy faecal material produced during pregnancy. usually released from bowels after birth but sometimes can pass in utero leading to MSAF
26
MSAF pathophysiology
the after effect of in utero peristalysis usually is the result of foetal hypoxic stress or vagal stimulation due to cord compression...also causes foetus to gasp once aspirated - stimulates release of vasoactive and cytokine substances...active inflammatory pathway and inhibits effect of surfactant
27
factors contributing to resp distress in MASF
partial/total airway obstruction - as meconium thick...atelectasis. Pulmonary pressure increases, right to left shunt through patent ductus arteriosus/foramen ovale...V/Q mismatch - foetal hypoxia - V/Q mismatch, increase pulmonary vascular pressures, mechanical obstruction - pulmonary inflammation - due to pro-inflammatory cytokines - infection - meconium good medium for organisms, inflammation process predisposes to - surfactant inactivation - increases surface tension of alveoli..reduced gas exchange - persistent pulmonary HTN - remodeling of pulmonary vascular bed in response to hypoxia
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major cause of morbidity and mortality in MSAF
PPHN
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risk factors for MSAF
Gestational Age > 42 weeks Foetal distress (tachycardia / bradycardia) Intrapartum hypoxia secondary to placental insufficiency Thick meconium particles Apgar Score <7 Chorioamnionitis +/- Prolonged pre-rupture Oligohydramnios In utero growth restriction (IUGR) Maternal hypertension, diabetes, pre-eclampsia or eclampsia, smoking and drug abuse
29
examination MSAF
Tachypnoea – a respiratory rate of >60 breaths per minute Tachycardia – a heart rate of >160 beats per minute Cyanosis – this requires immediate management Grunting Nasal flaring Recessions – intercostal, supraclavicular, tracheal tug Hypotension – systolic blood pressure of <70 mmHg
29
MSAF investigations
CXR -increased lung volumes asymmetrical patchy pulmonary opacities pleural effusions pneumothorax or pneumomediastinum multifoc infection markers dual pulse oximetry ECHO CRANIAL USS consolidation
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ddx MSAF
transient tachypnoea of newborn surfactant deficiency persistent pulmonary HTN
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management MSAF
observation - 02 sats infant warmer bloods IV fluids O2 via nasal cannula (92-97%) CPAP or intubated abx - if infection bolus of surfactant or lung lavage with surfactant inhaled NO corticosteroids
31
complications MSAF
air leak - pnumonothorax or pneumomediastinum PPHN cerebral palsy chronic lung disease
32
necrotising enterocolitis epidemiology
1-3/1000 births reduced 6 fold in breastfed infants
33
pathophysiology NEC
likely due to innate immune response to microbiota or premature infant's gut
34
risk factors NEC
Prematurity or very low birth weight (VLBW) Formula feeding Intrauterine growth restriction (IUGR) Polycythaemia Exchange transfusion Hypoxia
35
clinical features NEC
feeding intolerance vomiting - bile or blood stained abdo distention and haematochezia abdo tenderness abdo oedema erythema palpable bowel loobs systemic features - apnoea, lethargy, bradycardia, decreased peripheral perfusion
36
investigations NEC
plain abdo x ray - distended bowel loops, thickened bowel wall, intramural gas, pneumoperitoneum FBC, UE, blood gas, blood culture
37
staging NEC
bell scoring system 1 to 3 suspected, definite, advanced clinical features and radiological
38
prophylactic management NEC
antenatal steroids if premature delivery anticipated breastfeeding probiotics
39
medical management MEC
if stage 1 or 2 Withhold oral feeds for 10-14 days and replace with parenteral nutrition. IV antibiotics for 10-14 days based on local protocols. Systemic support in the form of ventilatory support, fluid resuscitation, inotropic support, correction of acid-base balance coagulopathy and/or thrombocytopenia.1
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indications for NEC
Intestinal perforation GI obstruction secondary to stricture formation Deterioration despite medical management1
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surgical management NEC
intestinal resection with stoma formation
43
complications NEC
intestinal perforation sepsis death long term - strictures, short bowel syndrome, neu
44
preterm birth definition
before 37 completed week's gestation Extreme preterm: before 28 weeks Very preterm: 28 to 32 weeks Moderate to late preterm: 32 to 37 weeks
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number 1 cause of neonatal death globally
prematurity
48
associations for neonatal death in premature delivery
life threatening conditions - pre eclampsia, renal disease due to premature rupture of membranes emergency event - placental abruption 40% have no identifiable cause
48
epidemiology pre term
15 million babies each year 60% in africa and south asia as well as high income countries
49
risk factors for premature delivery
Previous preterm delivery Multiple pregnancy Smoking and illicit drug use in pregnancy Being under or overweight in pregnancy Early Pregnancy (within 6 months of previous pregnancy) Problems involving cervix, uterus or placenta, including infection Certain chronic conditions such as diabetes and hypertension Physical injury/trauma
50
hx preterm labour
estimated due date last menstrual period assessment of gestational age
51
examination preterm infant
dubowitz/ballard exam for gestational age - assess neonatal maturity - external physical and neuomuscular features to avoid hypothermia physical features to assess - skin, lanugo, eye, ear and genital formation, posture and arm recoil
52
investigations preterm infant
blood gas FBC U+E blood culture CRP blood group and direct coombs test/direct antiglobulin test CXR abdo X ray cranial USS
53
central venous/arterial access in preterm infant
umbilical vein, atery
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initial management pre term infant
if planned - tertiary level neonatal unit antenatal steroids magnesium sulphate - neuroprotective
57
resuscitation guidlines pre term
Less than 23 weeks then resuscitation should not be performed Between 23 and 23+6 weeks then there may be a decision not to start resuscitation in the best interests of the baby, especially if parents have expressed this wish. Between 24 and 24+6 weeks, resuscitation should be commenced unless the baby is thought to be severely compromised After 25 weeks, it is appropriate to resuscitate and start intensive care.
58
resp system pre term
resp distress syndrome, surfactant deficient, CLD ...exogenous surfactant, intubation, CPAP, oxygen
59
CVS pre term
hypotension, PDA inotrope infusion, fluid, ibuprofen or indomethacin, ligation of PDA
60
neuro pre term infant
intraventricular haemorrhage, seizures, cerebral palsy...surveillance with cranial USS, head circumferences, antiepileptic drugs, referral, follow up, awareness of stimulation
61
GI pre term
feeding intolerance, NEC,..TPN, NG, maternal and donor expressed breast milk, abx
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renal premature
immature function monitor fluid and electrolyte, consider catheter
63
metabolic premature
jaundice, hyper or hypoglycaemia, inborn errors of metabolism...phototherapy, exchange transfusion, insulin infection, glucose via central IV access
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infection premature
sepsis, infection...sepsis screen, IV abx
65
skin premature
insensible losses and increased risk of infection...nursing in warm, humid intubator, ANNT
66
thermoregulation premature
immature...nursing in warm humid incubator, cot warmer, awareness of exposure
67
eyes premature
retinopathy of prematurity...avoid excess o2 exposure, screening, laser tx
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prognosis prematurit
survival rare <23 weeks by 26 weeks, 3/4 survive 90% at 27 weeks
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neurodevelopmental prognosis premature
gross motor delay fine morot speech and language learning and behaviour
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family support prematurity
eriods of kangaroo care/skin-to-skin should be encouraged. There are often local support groups available for parents and charities such as Bliss
73
ethics prematurity
complex...when to withdraw intensive care
74

Paediatrics (17 decks)

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