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Neonatology Flashcards

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1
Q

Define neonate, low birth weight, very low birth weight, and extremely low birth weight

A

First 28 days of age
<2.5kg
<1.5kg
<1 kg

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2
Q

What are appearance and maturational differences of very preterm infants?

A

Gestation 23-27 weeks
Birthweight: 600-700g
Skin: very thin, dark red colour all over body
Ears: Pinna soft, no recoil
Breast: no breast tissue palpable
Genitalia:
Male - scrotum smooth, no testes in scrotum (no rugae)
Female - Clitoris and labia minora protruding (not covered), labia Majora separated
Breathing: needs respiratory support, apnoea common
Sucking and swallowing: no coordinated sucking
Feeding: needs parenteral nutrition andntuve feedinf
Cry: faint
Vision: eyelids fused, infrequent eye movements, no eye contact/interaction
Hearing: startles to loud noise
Posture: limbs extended, jerky movements

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3
Q

Complications of prematurity

A 
Resuscitation 
Respiratory distress syndrome
Pneumothorax
Apnoea and bradycardia
Hypotension
Patent ductus arteriosus
Temperature control
Metabolic: hypoglycaemia, hypocalcaemia, electrolyte imbalance, osteopenia of prematurity
Nutrition
Infection
Jaundice
Intraventricular haemorrhage/periventricular leukomalacia 
Necrotising enterocolitis
Retinopathy of prematurity 
Anaemia of prematurity
Iatrogenic
Bronchopulmonary dysplasia
Inguinal hernia
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4
Q

What are the interventions in Resuscitation and stabilisation of preterm infants

A

A + B: clear airway, oxygen, CPAP or high flow nasal cannula, mechanical ventilation

C: 
Peripheral intravenous line
Umbilical venous line
Arterial line - if frequent blood gas or continuous BP monitoring 
PIC line for parenteral nutrition

Temperature:
Place in plastic bag
Stabilisation under radiant warmer, heated mattress, or humidified incubator (evaporative heat loss)

CXR
Broad spectrum antibiotics
Minimal handling (affects oxygenation and circulation)

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5
Q

Pathophysiology of respiratory distress syndrome

A

Surfactant is mixture of phospholipid/protein produced by T2 pneumoncytes that lowers surface tension
Deficient in surfactant
Alveolar collapse and impaired gas exchange

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6
Q

Clinical and radiographic features of respiratory distress syndrome

A

Tacypnoea >60/min
Laboured breathing: chest wall recession, nasal flaring
Expiratory grunting (to create positive pressure during expiration)
Cyanosis
CXR: granular, ‘ground glass’ appearance

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7
Q

Management of RDS

A

Raised ambient Oxygen therapy
Surfactant therapy via tracheal tube/catheter
Non-invasive ventilation: CPAP, High-flow nasal cannula
Mechanical ventilation

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8
Q

What are the features of oxygen therapy in preterm infants

A

21-30% oxygen used
91-95% O2 sats maintained
Because hyperoxia is damaging from excess free radicals, increased risk of retinopathy of prematurity
And low saturations increase risk of necrotising enterocolitis/death

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9
Q

Pathophysiology of pneumothorax in preterm infant

A

In RDS, air from alveoli may track into interstitium and cause pulmonary interstitial emphysema (air outside alveolar air space)
When ventilated, air leaks into pleural cavity and cause pneumothorax
Occurs in 10% infants ventilated for RDS

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10
Q

How can you detect pneumothorax in preterm infants

A

Transillumination with fibre optic light applied to chest wall
CXR

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11
Q

How can you prevent pneumothorax in preterm infants

A

Ventilated with lowest pressures that provide adequate chest movement and satisfactory blood gases

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12
Q

What are causes of bradycardia and apnoea in preterm infants

A 
Bradycardia: infant stops breathing for 20-30 seconds or against closed glottis
Immaturity of central respiratory control
Hypoxia
Infection
Anaemia
Electrolyte disturbance
Hypoglycaemia
Seizures
Heart failure
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13
Q

Management of apnoea in preterm infants

A

Physical stimulation

Caffeine

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14
Q

Why are preterm infants vulnerable to hypothermia

A

Large SA:Mass ratio - heat loss > heat generation
Skin thin and permeable - greater evaporative water loss
Little subcutaneous fat for insulation
Cannot conserve heat by curling up
Cannot generate heat by shivering

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15
Q

Why is it important to avoid hypothermia in preterm infants

A

Increased energy consumption
Hypoxia
Hypoglycaemia
Failure to gain weight

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16
Q

Measures for temperature control in newborn infants

A

Convection:
Raise temperature of air in incubator
Clothing
Avoid draughts

Radiation:
Cover baby
Double walled incubator

Evaporation:
Plastic bag at birth without drying
Humidify incubator

Conduction:
Heated mattress

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17
Q

What are clinical features of patent ductus arteriosus

A

Asymptomatic
Apnoea and bradycardia
Difficulty weaning from artificial ventilation (Respiratory problems from increased flow)

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18
Q

Management of patent ductus arteriosus

A

Diuretics + fluid restriction
Ibuprofen
Prostaglandin synthase inhibitor
Surgical ligation

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19
Q

Management of nutrition in preterm infants

A

NGT feeding: until 35-36 weeks gestational age, cannot suck and swallow milk

Fortified Breast milk:
introduced as soon as possible
Maternal, donor, formula
Phosphate, vitamin D, calcium supplements added (prevent osteopenia of prematurity)

Parenteral nutrition: PIC line or umbilical venous Catheter
Increased risk of sepsis or thrombosis in major vein

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20
Q

Pathophysiology of necrotising enterocolitis

A

Due to GI prematurity, bowel is vulnerable to ischaemic injury and bacterial infection

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21
Q

Risk factors for necrotising pancreatitis

A

Increasing prematurity
Cows milk formula feed
Rapid increase in feed

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22
Q

Clinical features of necrotising enterocolitis

A

Feed intolerance
Bilious vomiting
Abdominal distension, tense and shiny skin of abdomen
Blood stained stool
Shock
X Ray: intramural air, distended bowel loops, air in portal tract

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23
Q

Management of anaemia of prematurity

A

Nutrition

Iron supplements

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24
Q

What are the types of brain injuries in preterm infants

A

Haemorrhage: germinal layer, intraventricular, parenchymal (+infarction)

Ventricular dilatation: due to large IVH, can resolve or progress
Tx with LP, ventriculoperironeal shunt

Periventricular white matter injury:
Ischaemic white matter injury
Periventricular leukomalacia - bilateral multiple cysts on cranial USS

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25
Risk factors for brain injuries in infants
Perinatal asphyxia RDS Pneumothorax
26
Consequences of brain injuries in preterm infants
Hemiplegia Hydrocephalus Cerebral palsy
27
What is bronchopulmonary dysplasia
Need for supplemental oxygen for at least 28 days after birth Aka chronic lung disease
28
Cause of BPD
Delay in lung maturation Trauma from mechanical ventilation Oxygen toxicity Infection
29
Management of BPD
Early extubation: wean to CPAP or high flow nasal cannula | Caffeine therapy: for apnoea
30
Prognosis of BPD
Need for home oxygen therapy | No other long term lung complications
31
Prevalence of neonatal jaundice
50% neonates | 80% preterm infants
32
Classification of neonatal jaundice
Physiological: appears 2-4 days after birth and resolves 1-2 weeks later Pathological: any jaundice in first 24 hours of life Prolonged: jaundice for > 2 weeks or >3 weeks in premature neonate
33
Physiology of neonatal jaundice
Physiological: Increased RBC turnover and Increased Hb lysis due to increased adult Hb synthesis and breakdown of fetal Hb Less efficient hepatic bilirubin metabolism
34
Causes of pathological neonatal jaundice
<24hours: Haemolytic anaemia - Rhesus/ABO incompatibility, G6PD deficiency, spherocytosis Congenital infection - TORCH ``` 24hrs - 2 weeks: Physiological Breast milk jaundice Infection Haemolysis Bruising Polycythaemia Inborn errors of metabolism (Crigler-Najjar Syndrome ) ``` ``` >2weeks: Unconjugated - Physiological, Breast milk jaundice Infection (UTI) Hypothyroidism Haemolytic anaemia Upper GI obstruction Conjugated - Bile duct obstruction Neonatal hepatitis TPN ```
35
What is breast milk jaundice
Unconjugated jaundice, Jaundice more prolonged and common in breastfed infants
36
What is Crigler-Najjar Syndrome
Rare syndrome of glucuronyl transferase deficiency causing defective conjugation and unconjugated jaundice
37
Investigations for neonatal jaundice
Transcutaneous bilirubinometer: screening test for all babies in first 72hrs of life Total serum bilirubin: confirms diagnosis, pathological >205 ``` Direct Coombs test Direct serum bilirubin FBC Peripheral blood smear Blood groups ```
38
Assessment of neonatal jaundice
Severity: blanching skin (starts at head and spreads down), transcutaneous bilirubinometer, total serum bilirubin Gestation: lowers threshold for intervention Age: <24hrs haemolytic anaemia likely, >2wks need to check conjugated or unconjugated Well or unwell: evidence of sepsis, dehydration Investigations
39
Management of neonatal jaundice
Unconjugated: Phototherapy Hydration Exchange transfusion Kernicterus: Immediate exchange transfusion Conjugated: Treat underlying cause Breast milk jaundice: Temporary cessation of breast feeding and supplemental feeding
40
What is phototherapy
Blue-green light delivered, to convert unconjugated bilirubin into harmless water soluble pigment excreted in urine Contraindicated in conjugated jaundice: bronze discolouration of skin
41
What is exchange transfusion
Blood removed from baby in small aliquots and replaced with donor blood Indicated if bilirubin Levels rise to dangerous levels Immediate transfusion required If signs of kernicterus
42
What is kernicterus
Encephalopathy from deposition of unconjugated bilirubin in basal ganglia and brainstem nuclei Bilirubin is neurotoxic (impairs mitochondrial function and metabolism) and preferentially taken up by basal ganglia, caudate nuclei, putamen, globus pallidus Hyperbilirubinaemia high risk in neonates - developing BBB allows for bilirubin to enter CNS
43
Clinical features of kernicterus
Early: lethargy, hypotonia, poor sucking, high pitched cry Intermediate: irritable, variable tone, high pitched cry Advanced: hypertonia - opisthotonos (arched back), deep stupor or coma
44
Long term consequences of kernicterus
Choreathetoid cerebral palsy Learning difficulties Sensorineural deafness
45
Management of necrotising enterocolitis
Prevention: antenatal steroids, human breast milk feed, probiotic supplementation Stop oral feed Broad spectrum antibiotics Parenteral nutrition Ventilation and circulatory support Surgery: complications - short gut syndrome, TPN dependence, chronic cholestasis
46
Define hypoxic-ischaemic encephalopathy
Hypoxic-ischaemic injury to brain due to perinatal asphyxia
47
Pathophysiology of HIE
Perinatal hypoxia-ischaemic event Cardiorespiratory depression Hypoxaemia, Hypercarbia -> Respiratory acidosis Reduced cardiac output -> Reduced tissue perfusion -> Metabolic acidosis Encephalopathy + multi-organ dysfunction Reperfusion injury and secondary neuronal damage
48
Clinical features of HIE
``` Mild: Irritable Responds excessively Hyperventilation Hypertonia Impaired feeding ``` ``` Moderate: Abnormal response/movement Hypotonia Cannot feed Seizures ``` Severe: No spontaneous movement, no response to pain Fluctuating tone Seizures - prolonged and refractory to treatment Multi-organ failure
49
Management of HIE
``` Resuscitation and stabilisation: Respiratory support Tx Hypotension with fluid and inotropes Fluid restriction for renal impairment Anticonvulsants for seizures Tx hypoglycaemia, electrolyte imbalance ``` Amplitude-integrated EEG: To confirm encephalopathy and detect seizures Mild therapeutic hypothermia: Cooling with cooling blanket within 6hrs of birth to temp 33 For mod-severe HIE: improve survival wo disability Neuroprotection from reperfusion injury
50
Prognosis of HIE
Mild: complete recovery Clinical abnormalities persist >2 weeks: poor Severe: high mortality, high risk of CP
51
Define perinatal/birth asphyxia
Evidence of hypoxia antenatally or during labour Resuscitation needed at birth Features of encephalopathy Evidence of hypoxic damage to other organs No other cause identified (e.g. kernicterus)
52
Classification of neonatal infection
Early onset: <48hrs after birth | Late onset: >48hrs after birth
53
What are the red flag risk factors for neonatal sepsis
Invasive GBS infection in previous baby Maternal GBS colonisation/bacteriuria/infection current pregnancy PROM Preterm birth Following spontaneous labour Rupture of membranes >18hrs in a preterm birth Intrapartum Fever >38, suspected/confirmed chorioamnionitis
54
What are the red flag clinical features of neonatal sepsis
Jaundice within 24 hrs Altered behaviour or responsiveness Altered muscle tone Feeding difficulties Feed intolerance - vomiting, excessive gastric aspirates, abd distension Abnormal HR Signs of respiratory distress Hypoxia Apnoea Signs of neonatal encephalopathy Need for cardio-pulmonary resuscitation Need for mechanical ventilation in term baby Persistent fetal circulation (persistent pulm hypertension) Temperature abnormality (<36, >38) unexplained by enviro factors Unexplained excessive bleeding, thrombocytopenia, abnormal coagulation Oliguria persisting beyond 24hrs after birth Hypo/hyperglycaemia Metabolic acidosis Local signs of infection
55
Causative organisms of early onset infection
GBS E. Coli Listeria monocytogenes
56
Clinical features of neonatal meningitis
``` Tense or bulging fontanelle Head retraction (opisthotonos) ```
57
Investigations for neonatal sepsis
``` Blood culture FBC CRP Swabs/urine If signs of local infection present Lumbar puncture ```
58
Antibiotics for neonatal infection
IV benzylpenicillin + gentamicin | Cover gram +ve and -ves
59
What types of infections does GBS cause and how do they present
Early onset: pneumonia, sepsis, meningitis | Late onset: meningitis, osteomyelitis, septic arthritis
60
How is Listeria monocytogenes transmitted
To mother In food - unpasteurised milk, soft cheese, undercooked poultry Causes bacteraemia and transmission to baby via placenta
61
Clinical features of neonatal L monocytogenes infection
``` Meconium stained liquor Wide spread rash Pneumonia Sepsis Meningitis ```
62
How is HSV transmitted and what is the risk of transmission
During passage through birth canal Ascending infection of amniotic fluid High if primary infection in late pregnancy Low if recurrent maternal infection
63
Consequences of neonatal herpes
Localised herpetic lesions on skin, eye Encephalitis Sepsis
64
Management of umbilical infection
Systemic antibiotics Silver nitrate Ligature around base of stump
65
Causes of sticky eyes in neonates
Physiological Staph/strep infection Gonoccocal incecfion Chlamydia trachomatis
66
Clinical features for each cause of sticky eyes
Physiological: washes off with saline/water Staph/strep: troublesome discharge, redness of eye Gonococcal: purulent discharge, conjunctival injection, lid swelling, within 48 hrs Chlamydia: purulent discharge, lid swelling, at 1-2 weeks
67
Management of hepatitis B infection
Infants of mothers HBsAg positive - hepatitis B vaccination
68
Clinical features of respiratory distress in term infants
Tachypnoea (>60) Dyspnoea - recession, nasal flaring Expiratory grunting Cyanosis
69
Causes of respiratory distress in term infants
``` Transient tachypnoea of newborn Pneumonia Meconium aspiration Milk aspiration Persistent pulmonary hypertension of newborn Diaphragmatic hernia Non-pulmonary: CHD, anaemia, HIE ```
70
What is transient tachypnoea of newborn
Respiratory distress due to delay in resorption of pulmonary fluid
71
Clinical features of transient tachypnoea of newborns
More common in birth by Caesarian Self limiting - resolves in first 3 days CXR - fluid in horizontal fissure
72
What is meconium aspiration syndrome
Respiratory distress due to meconium aspiration | Meconium causes mechanical obstruction, chemical irritation and predisposes to infection
73
Clinical features of meconium aspiration syndrome
Post term infants | CXR - hyperinflated, patchy consolidation and collapse
74
Causes of pneumothorax in newborns
Spontaneous Meconium aspiration RDS Mechanical ventilation
75
Causes of milk aspiration
Premature infants Neurological damage Bronchopulmonary dysplasia Cleft palate
76
What is persistent pulmonary hypertension of newborn
Life threatening condition of multiple causes, which leads to right-to-left shunting at lungs, atria and ductus arteriosus
77
What is persistent pulmonary hypertension of newborn
Life threatening condition of persisting high pulmonary vascular pressures, leading to right-to-left shunting
79
Risk factors for persistent pulmonary hypertension of newborn
Birth asphyxia Meconium aspiration Sepsis RDS
80
Management of persistent pulmonary hypertension of newborn
``` Mechanical ventilation Circulatory support Inhaled nitric oxide (vasodilator) High-frequency ventilation ECMO (heart and lung bypass) ```
81
What is diaphragmatic hernia
Left-sided Herniation of abdominal contents through posterolateral Foramen of diaphragm
82
Clinical features of diaphragmatic hernia
``` Antenatal diagnosis Failure to respond to resuscitation Respiratory distress Cyanosis at birth Apex beat and heart sounds displaced to right Poor air entry on left ```
83
Risk factors for respiratory distress syndrome
``` Extreme pre-term (23-25wks) Chorioamnionitis Birth weight Antpartum haemorrhage - blood inhibits surfactant GDM IUGR favourable - due to stress hormones ```
84
Clinical importance of birth size
Common - 7% Influences medical conditions encountered in neonatal life Accounts for 70% of neonatal deaths
85
Define SGA
Birth weight <10th centile for gestational age Can be benign or pathological If <2nd centile - Increased risk of congenital anomalies and neonatal problems
86
Define IUGR
Failure to reach genetically determined growth potential
87
Patterns of growth restriction
Asymmetrical | Symmetrical
88
Pathophysiology and Causes of asymmetrical growth restriction
Uteroplacental dysfunction in late pregnancy - head growth spared in expense of glycogen and fat : Pre eclampsia Multiple pregnancy Smoking
89
Pathophysiology and causes of symmetrical growth restriction
Prolonged poor growth: Chromosomal disorder, syndromes Maternal medical conditions Malnutrition
90
Fetus and infant Risks from growth restriction
Fetus: Stillbirth Perinatal asphyxia ``` Infant: Hypothermia Hypoglycaemia - Low glycogen and fat stores Hypocalcaemia Polycythaemia ```
91
Recommended duration of breastfeeding
6 months
92
Advantages of breastfeeding
Ideal nutrition for first 6 months Reduced risk of GI/Resp infections, otitis media Reduced risk of NEC in preterm infants Reduced risk of Obesity, DM, HTN in later life Improved mother-child relationship
93
Breast milk components
Colostrum: higher protein + immunoglobulin content Humoral immunity: IgA, Lactoferrin (inhibit e Coli), Bifidus factor (promote lactobacillus), lysozyme (bacteriolytic), interferon (antiviral) Cellular immunity: macrophages, lymphocytes Nutrition: protein, lipid, lipase, iron, vitamins, low solute load, long chain polyunsaturated fatty acids
94
Complications of breastfeeding
Unknown intake - monitor growth on growth centile chart Transmission of infection - cmv, hiv, Hep b Transmission of drugs Transmission of environmental contaminants - alcohol, nicotine, caffeine Vitamin K deficiency Breast milk jaundice Nutrient inadequacies beyond 6 months
95
What is formula feeding and how long do you recommend this for
Modified Cows milk | 12 months
96
When can you start cows milk | Why not earlier
After 12 months | Low iron and vitamin A, C, D content
97
What is specialised formula
Non cows milk based formula
98
Indications for specialised formula
``` Cows milk protein allergy Preterm Lactose intolerance Cystic fibrosis Neonatal cholestatic liver disease Neonatal intestinal resection Reflux ```
99
Differences in specialised formula milk
Higher calorie and mineral content Hydrolysed cows milk protein No lactose Fat from medium chain FA - no need for lipase/bile salts Anti reflux milk - rice starch causes milk to become viscous in stomach
100
When do you start weaning
6 months

Paediatrics (15 decks)

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