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Paediatrics > Neonatology & Common postnatal problems > Flashcards

Neonatology & Common postnatal problems Flashcards

1
Q

When does the CVS begin to develop?

A

Begins to develop 3rd week

Heart starts to beat at the beginning of 4th week

Critical period heart development is from day 20 to day 50 after fertilisation

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2
Q

What is the patent ductus arteriosus between?

A

Pulmonary artery to aorta

  • Protects lungs against circulatory overload
  • Allows the tight ventricle to strengthen
  • Carries low O2 saturated blood
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3
Q

What is the ductus venosus and what is the role of it?

A

Foetal blood vessel connecting the umbilical vein to the IVC (blood flow regulated via sphincter)

Carries mostly oxygenated blood from the placenta into the body of the foetus

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4
Q

How long does it take for the ductus arteriosus to close after first breath?

A

Usually takes up to 6 hrs but sometimes it could take up to 72 hrs

In a small amount it doesn’t close at all q

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5
Q

How long does it take for the ductus arteriosus to close after first breath?

A

Usually takes up to 6 hrs but sometimes it could take up to 72 hrs

In a small amount it doesn’t close at all

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6
Q

What is the normal HR of a newborn?

A

120-160 BPM

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7
Q

How do newborns do thermoregulation?

A

Newborn babies lack shivering thermogenesis thus need a metabolic production of the heat

Brown fat is well innervated by sympathetic neurons

Cold stress leads to lipolysis and heat production

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8
Q

How can we lose heat and what is done to prevent this?

A

Radiation:
Heat dissipated to colder objects.
Convection:
Heat loss by moving air.
Evaporation:
We are born in the water.
Conduction:
Heat loss to surface on which baby lies

Resuscitaire-preheated, hat available, sides up to prevent draft, warm towels for drying baby, all warm environment

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9
Q

How can newborn breathing be assessed?

A

Non invasive:
Blood gas determination
- PaCO2 5-6 kPa, PaO2 8-12 kPa
Trans-cutaneous pCO2/O2 measurement

Invasive (intubated baby):
Capnography
Tidal volume 4-6 ml/kg
Minute ventilation: Tidal Volume ml/kg x respiratory rate
Flow-volume loop.

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10
Q

What is physiological jaundice and how long does it last?

A

Appears on Day of life (DOL) 2-3-Disappears within 7-10 DOL in term infants and up to 21 DOL in premature infants.

Up to 60% terms and 80% premature babies develop visible jaundice.

75% bilirubin comes from haemoglobin-Metabolised, conjugated in liver.

Bilirubin is lipid soluble thus crosses haemato-encephalic barrier.
At high concentrations it cause an irreversible changes in the brain – kernicterus.

Blue light converts bilirubin to water soluble form and increases oxidation of bilirubin.

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11
Q

What is normal in terms of fluid balance in the term newborn?

A

Full term infant is able to maintain fluid / electrolyte balance.

Weight loss up to 10% is normal.
Loss is due to:
- Shift of interstitial fluid to intravascular
- Diuresis

It is normal not to pass urine for the first 24 hrs!

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12
Q

In premature infants they have less fat in body composition. Why do they have increased loss of fluid?

A

Increased loss through kidney:
- Slower GFR
- Reduced Na reabsorption
- Decreased ability to concentrate or dilute urine

Increased Insensible Water Loss (IWL)
- Via immature skin and breathing
- Physiological IWL is 20-40 ml/kg/day but could be up to 82 ml/kg/day in 750-1000 g

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13
Q

How does the physiological anaemia of the newborn occur?

A

RBC production is 10% of in uterus DOL 7

Born with - Hb 15-20 g/l
Week 10 - Hb 11.4 g/l
Increase production of Erythropoietin
Week 20 - Hb 12.0 g/l

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14
Q

What can cause anaemia of prematurity?

A

Reduced erythropoesis.

Infection

Blood letting – most
important cause!

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15
Q

When is term classified?

A

Babies born at 37 weeks gestation and above

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16
Q

What are the symptoms of sepsis to look out for in a newborn?

A

Symptoms
Baby pyrexia or hypothermia
Poor feeding
Lethargy or irritable
Early jaundice
Tachypnoea
Hypo or hyperglycaemia
Floppy
Asymptomatic

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17
Q

What are the symptoms of sepsis to look out for in a neonate?

A

Symptoms
Baby pyrexia or hypothermia
Poor feeding
Lethargy or irritable
Early jaundice (first 24hrs)
Tachypnoea
Hypo or hyperglycaemia
Floppy
Asymptomatic

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18
Q

What are the risk factors for sepsis in a newborn?

A

PROM (waters broken for >24hrs before baby delivered-risk of chorioamnionitis)
Maternal pyrexia
Maternal GBS carriage

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19
Q

How is presumed sepsis of a neonate managed?

A

Admit NNU

Partial septic screen (FBC, CRP, blood cultures) and blood gas

Consider CXR, LP

  • IV penicillin and gentamicin 1st line
  • 2nd line IV vancomycin and gentamicin
  • Add metronidazole if surgical/abdominal concerns

Fluid management and treat acidosis
Monitor vital signs and support respiratory and cardiovascular systems as required

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20
Q

What are the commonest causes of neonatal sepsis?

A

1) Group B strep
2) E.coli
2) Listeria
4) Coag-neg Staph (if lines in situ)
5) Haemophilus influenzae

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21
Q

GBS Sepsis: when is early and when is late onset and what are the complications of it?

A

Early onset – birth to 1 week
Late onset or recurrence – up to 3 months

Symptoms – may be non specific
May have no risk factors

Complications:
Meningitis, DIC, pneumonia and respiratory collapse, hypotension and shock

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22
Q

What is the TORCH screen for congenital infection?

A

Toxoplasmosis (undercooked meat and handling cat litter)
‘Other’ (syphilis & VZV)
Rubella
Cytomegalovirus (CMV)
Herpes simplex virus (HSV)

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23
Q

What may congenital infections result in?

A

IUGR, brain calcifications, neurodevelopmental delay, visual impairment, recurrent infections

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24
Q

What is blueberry muffin rash (purple papulonodular rash) typically seen in?

A

Rubella

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25
Q

Resp distress is one of the commonest reasons for admission to NNU: what are the causes of it?

A
  • Sepsis
  • TTN-transient tachypnoea of the newborn
  • Meconium aspiration
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26
Q

What are some signs of resp distress?

A
  • Subcostal recessions
  • Grunting (expiring against a partially closed glottis)
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27
Q

When does TTN present and what is the management of it?

A

Self limiting and common

Presents within 1st few hours of life

Grunting, tachypnoea, oxygen requirement, normal gases

Pathophysiology
Delay in clearance of foetal lung fluids

Management
Supportive, antibiotics, fluids, O2, airway support

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28
Q

What can be seen on a CRX in TTN?

A

Wet lungs with prominent vascular markings

Fluid in the horizontal fissure

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29
Q

What is meconium aspiration and what are the symptoms?

A

Meconium is inhaled into the lungs

Symptoms:
- Cyanosis
- Increased work of breathing
- Grunting
- Apnoea
- Floppiness

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30
Q

What are the risk factors for meconium aspiration?

A
  • Post dates (Term +)
  • Maternal diabetes
  • Maternal HT
  • Difficult labour
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31
Q

How do you investigate for meconium aspiration?

A
  • Blood gas
  • Septic screen
  • CXR
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32
Q

What is the treatment and prognosis of meconium aspiration?

A

Treatment:
- Suction below cords
- Airway support - intubation and ventilation
- Fluids & Abx IV
- Surfactant
- NO (vasodilator) or ECMO (lung bypass)

Prognosis:
- Most do well
- Some develop PPHN
- Associated mortality

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33
Q

Most cardiac murmurs of no consequence & don’t need admission to NNU, which ones do?

A

Them blue babies -need urgent treatment

(sepsis and resp distress causes more common than cardiac)

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34
Q

What is done to investigate blue babies?

A
  • H&E
  • Sepsis screen
  • Blood gas & BG
  • CXR
  • Pulse oximetry
  • ECG
  • ECHO
  • (hyperoxia test- breathe 100% O2 to help differentiate between cardiac and lung disease)
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35
Q

What are some main causes of cyanotic congenital cardiac disease (5 T’s!!!)

A

Truncus arteriosus
TGA
Tricuspid atresia
ToF
TAPVD

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36
Q

What weight category shows that a baby is born small?

A

<2.5kg

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37
Q

What weight category shows that a baby is born small?

A

<2.5kg (small for gestational age)

Small for gestational age is the babies born under the weight of the 10th centile

  • Small for gestational age (SGA)
  • IUGR
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38
Q

What are some maternal problems that could make a baby small for dates?

A
  • Smoking
  • Maternal pre-eclamptic toxaemia (PET)
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39
Q

From the foetal point of view what could make a baby small for dates?

A
  • Chromosomal e.g. Edward’s syndrome (Trisomy 18)
  • Infection e.g. CMV
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40
Q

What can go wrong with placenta that can make a baby small for dates?

A
  • Placental abruption
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41
Q

Twin pregnancy can be a reason for babies being small for dates. Is this true?

A

Yes it is indeedy

  • Twin to twin transfusion
  • Donor babies usually smaller
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42
Q

What are some common problems that the babies experience who are small for dates?

A
  • Perinatal hypoxia
  • Hypoglycaemia
  • Hypothermia
  • Polycythaemia
  • Thrombocytopaenia
  • GI problems (feeds, NEC)
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43
Q

What is extreme preterm?

A

Under 1 kg, & under 28 weeks

44
Q

RDS (caused by surfactant deficiency): How can it be prevented and treated?

A

Prevention
- Antenatal steroids

Early treatment
- Surfactant

Early extubation
Non-invasive support (N-CPAP)
Minimal ventilation (low tidal volume & good inflation)

45
Q

BPD/CLD is a complication of RDS: what causes it and how is it treated?

A

Overstretch by volu-baro-trauma

Atelectasis

Infection via ETT

O2 toxicity

Inflammatory changes
Tissue repair - scarring

Treatment:
- patience
- nutrition & growth
- steroids (!)

46
Q

What are some minor problems of the resp system that can occur in preterms?

A

Apnoea/irregular breathing/desaturations

Treatment:
- Caffeine
- N-CPAP

47
Q

How is IVH prevented and treated?

A

Prevention
AN steroids

Treatment=Symptomatic

48
Q

What is PVL?

A

Injury to white matter in the watershed area

49
Q

What is a major complication of IVH?

A

PHH (post haemorrhagic hydrocephalus) - blood products block draining system of CSF in the brain

Treatment= Ventricular peritoneal shunts

50
Q

What can happen with a PDA in preterm infant?

A

Pressure Ao>PA - L to R shunt:

Additional blood to pulmonary circulation
- over-perfusion of lugs
- lung edema
+
steal from systemic circulation
- systemic ischemia

51
Q

What are the consequences of a PDA?

A

Worsening of respiratory symptoms
+
Retention of fluids (low renal perfusion)
Gastrointestinal problems (GE ischemia-become susceptible for NEC)

52
Q

What is NEC caused by and what is the management?

A

Ischemic & inflammatory changes

Necrosis of bowel

Surgical intervention is often required

Conservative management is sometimes possible=antibiotics & parenteral nutrition

53
Q

There is enormous nutritional requirements in preterm, why is this?

A

Patients often triple their size during hospital stay

Building new functional tissues from compounds provided artificially

54
Q

The outcome of extreme prematurity are unpredictable at the time of birth, how is it predicted later on?

A

Ultrasound of brain by the end of 1st week

Often very uncertain even on discharge home

Surprising deterioration (cognitive and behavioural) between year 2nd and year 6th

Also some unexpected improvement between 2nd and 6th year of life

Extremely limited data on subjective quality of life in adulthood

55
Q

How should Hypoglycaemic term infants be managed who have symptoms of low BG or who have persistent low BG?

A

If requires admission to NNU may still manage with enteral feeds
Monitor blood glucose

Start iv 10% glucose
Increase fluids
Increase glucose concentration (central iv access)
Glucagon
Hydrocortisone

56
Q

What should be done in a case of Hypothermia?

A

If unable to maintain temp on PNW admit and place in incubator

Sepsis screen & Abx

Consider checking thyroid function (congenital hypothyroidism)

Monitor BG

57
Q

What may be required in a case of severe jaundice?

A

Admission for intensive phototherapy &/or exchange transfusion

Incubator & IV fluids may be required

58
Q

What is birth asphyxia and what can cause it?

A

Lack of O2 at or around birth leads to multiorgan dysfunction

Causes:
- Placental problem
- Long, difficult delivery
- Umbilical cord prolapse
- Infection
- Neonatal airway problem
- Neonatal anaemia

59
Q

What are the stages of birth asphyxia?

A

1st=Within minutes=cell damage occurs with lack of BF & O2

2nd= Reperfusion injury-can last days or weeks=toxins are released from damaged cells

60
Q

What is hypoxic ischaemic encephalopathy?

A

The pattern of brain injury that occurs secondary to birth asphyxia

Diagnosis based on biochemical evidence of birth asphyxia - found on cord blood gases that should be taken at the time of delivery & also blood gases found shortly after delivery

  • Abnormalities on neuro exam

Mild, moderate or severe HIE

61
Q

What is the management of HIE?

A
  • Supportive care
  • Therapeutic hypothermia(cooling) improves outcome esp in moderate group
  • Treat seizures (also look for subclinical seizure)
  • Fluid restriction (avoid cerebral oedema)
  • Resp & cardiac support
62
Q

What are some causes of failure to pass stool?

A

Large bowel atresia

Imperforate anus +/- fistula

Hirschsprung’s disease

Meconium plug

Meconium ileus -think CF

63
Q

What are 2 common abdominal wall defects seen that are a surgical problem?

A

Exomphalos (Herniation of abdo contents covered by a sac)-associated commonly with a congenital anomaly (most commonly cardiac)

Gastroschisis (Herniation of bowel contents not covered by a protective sac)-tends to be an isolated defect

64
Q

Congenital diaphragmatic hernia: what is is caused by and how is it managed?

A

Defect in the formation of the diaphragm which means the bowel contents herniates up into the chest-essentially this becomes a problem with lung development

90% on left
Male > female
- Can be syndromic
- Usually pulmonary hypoplasia

Intubation at birth
Respiratory support

Surgery after NG tube to decompress bowel
(ECMO)

65
Q

On what side is the congenital diaphragmatic hernia most likely to occur?

A

90% on left

66
Q

What is neonatal abstinence syndrome (NAS)?

A

Withdrawal from physically addictive substances taken by the mother in pregnancy

Opioids (methadone, heroin)
Benzodiazepines
Cocaine
Amphetamines

67
Q

How is NAS diagnosed and treated?

A

Monitoring/Diagnosis:
Finnegan Scores (looking for features of NAS)
Urine toxicology

Maternal co-morbidity (smoking, alcohol, BBV, ill health)
Social & discharge planning

Treatment:
Comfort (e.g. swaddling)
Morphine (isolated opioid use in mother)
Phenobarbitone (poly drug abuse or use to treat more severe cases)

68
Q

If sepsis is suspected when should you start Abx?

A

Within 1 hr

69
Q

RR>60 or signs or RDS are common reasons for admission what could they point towards?

A

Mild=TTN
Severe=MAS, Sepsis

70
Q

When is the top to toe newborn examination done?

A

Within 72 hrs of their birth

71
Q

What is plethora?

A

Reddy skin colour-may be due to abnormalities of blood vessels in utero, polycythaemia etc

Bloods-look at haematocrit

72
Q

When is blue peripheries normal?

A

Extremely common in the newborn period and is part of the normal transition

73
Q

Why does physiological jaundice occur?

A

Increased red cell turnover so bilirubin is produced from the breakdown of Haem in red blood cells & also immaturity of hepatic enzymes which process bilirubin

Normal physiological jaundice causes an unconjugated hyperbilirubinemia

74
Q

When does physiological jaundice occur?

A

Between 2nd day of life and 2nd week in term or 3rd week in pre-terms

75
Q

Why is it important to check the conjugated bilirubin factor in cases of prolonged jaundice?

A

As cholestasis would be identified by conjugated jaundice

76
Q

How is jaundice treated?

A
  • Treat underlying causes
  • Hydrate
  • Phototherapy-NICE guideline charts (based on gestation)
  • Exchange transfusion
  • Immunoglobulin
77
Q

Why does physiological type jaundice often get treated?

A

Unconjugated bilirubin levels if they become too high can cause neuro-toxic effects

78
Q

What is erythema toxicum?

A

Maculo-papular rash

Very rare in pre-term

Rash fades by end of 1st week

No Rx is required

79
Q

Mongolian blue spots (blue-grey pigmentations) are very common: what are they caused by and where are they often seen?

A
  • Accumulation of melanocytes
  • Very common- races with pigmented skin-less obvious as skin darkens
  • Often: Lower back + buttocks
80
Q

Stork marks (Naevus Simplex)-are caused by what and where are they commonly found?

A

Light colour capillary dilation commonly found at back of neck (maybe along midline of face)

Gradually fades within the first 2 yrs

81
Q

Naevus flammeus (port wine stain) do not regress: what are they caused by and what is it associated with?

A

Present at birth, flat or slightly raised

Caused by dilated, mature capillaries in the superficial dermis

Associations:
- Sturge Weber
- Klippel-Trenaunay

82
Q

What is a capillary haemangioma (strawberry naevus)?

A

A cluster of dilated capillaries which appears within the first month after birth

Raised & bright red, with discrete edges, occurring in any part of the body

Usually regresses after 1yo (B blocker treatment if needed)

83
Q

What does the energy triangle involve (think warm, pink and sweet)?

A

Pillars of new-born care are to avoid:

  • Hypothermia
  • Hypoxia/anoxia
  • Hypoglycaemia
84
Q

Why are newborns more susceptible to hypothermia?

A

High surface area to volume ratio, born wet and they come into contact with cold environments & surfaces

85
Q

How is resuscitation and cold stress managed?

A
  • Dry quickly
  • Remove wet linens
  • Use warm towels/blankets
  • Provide radiant warmer heat
  • Use heated/humidified O2
86
Q

What is hypoglycaemia in the first 48 hrs of life of a term baby defined as?

A

BG < 2mmol/l

87
Q

When could BG bedside testing be inaccurate?

A
  • At low or high levels
  • When there is poor perfusion
  • When there is polycythaemia (high Hct)

Check a lab sample if there are concerns

88
Q

What babies are at risk of hypoglycaemia?

A
  • Limited Glc supply (premature babies, perinatal stress)
  • Hyperinsulinism, (infants of diabetic mothers)
  • Increased Glc use (hypothermia, sepsis)
89
Q

What are some symptoms of Hypoglycaemia?

A
  • Jitteriness
  • Temp instability
  • Hypotonia
  • Apnoea, irregular resps
  • High pitched or weak cry
  • Seizures
  • Asymptomatic
90
Q

What is tongue tie and when should it be treated (mostly no treatment necessary)?

A

Short +/- thickened frenulum- attached anteriorly to base of tongue

Restriction of tongue protrusion beyond the alveolar margins AND feeding is affected=Frenotomy

91
Q

Bilious vomiting (fairy liquid green) is what until proved otherwise?

A

Bowel obstruction

92
Q

How do you evaluate a newborns resp?

A
  • RR (>60 min)
  • Increased effort (grunting, retractions, nasal flaring)
  • Colour
  • O2 saturations
93
Q

Where are the areas to assess for retractions (resp)?

A

Substernal
Subcostal
Intercostal
Suprasternal

94
Q

Why is it important to check for absent/weak femoral pulses?

A

Can indicate coarctation of the aorta (duct dependant cardiac disease)

(Look at BPs in arms and legs, ECG as investigations)

95
Q

What are the categories of cleft lip and what causes them?

A

70% of cases also have cleft palate

Can be incomplete (small gap in lip) or complete (continue into the nose)

Can be unilateral (left sided most common) or bilateral

Maxillary & medial nasal processes fail to merge, usually around 5 weeks gestation

96
Q

What are the issues and associated anomalies of cleft palate/lip?

A
  • Feeding issues (special bottles & teats, can still attempt breast feeding)
  • Airway problems
  • Associated anomalies:
    need hearing screen and cardiac echo and remember trisomies
97
Q

What ophthalmological conditions are screened for in newborns?

A

Always check red reflexes

CATARACTS (lens opacification, if undetected early could lead to blindness, may require lens removal and artificial lens)

RETINOBLASTOMA (leukocoria (red white reflex)- cancer which can be treated if picked up early-laser therapy, chemo, surgical removal of the eye)

98
Q

What can spinal dimples show?

A

Can reveal a more serious abnormality involving the spine &/or spinal cord such as spina bifida occulta which is the least serious form of spina bifida +/- tethered cord

If the dimple is large, off midline, high or with other cutaneous marker (e.g. hairy tuft)—-Spinal imaging

99
Q

What is a cephalohematoma and what is the treatment?

A

Localised swelling over one or both sides of the head-becomes maximal size by the 3rd to 4th day of life

Soft, non translucent swelling-limits are those of one of the cranial bones-usually parietal bone-haemorrhage is beneath the pericranium

No treatment is required and resolution occurs in 3-4 weeks

No association with intracranial bleeding

100
Q

Cephalohematoma: What occasionally if the haematoma is very large what can occur?

A

Increased haemolysis results in increased or prolonged neonatal jaundice

101
Q

What do talipes require as treatment?

A

Medial (varus) or lateral (valgus) deviation of the foot is often positional and requires no treatment other than physio

Fixed talipes require more vigorous manipulation, strapping, casting or possible surgery

102
Q

Babies with significant talipes may also have?

A

Developmental dysplasia of the hips (DDH)

103
Q

What are the tests for DDH?

A

Barlow Test (adduct hip, backwards pressure to see if joint will slip out)

Ortolani test (abduct hip- already dislocated slip back into place)

Urgent USS if hear click or a clunk

104
Q

What is the DDH treatment?

A

Goal is to relocate head of femur to acetabulum so hip develops normally

Pavlik harness

Surgical reduction

105
Q

What are the signs of Trisomy 21?

A

Dysmorphism (low set ears, upward slanting palpebral fissures, epicanthic folds, single palmar creases, wide sandal gap)

Hypotonia (floppy baby-decreased muscle tone)

Cardiac defects

Learning Problems

Haematological problems

Thyroid problems

Paediatrics (17 decks)

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