Paediatrics Neonatology Flashcards
(197 cards)
1
Q
What is surface tension?
A
Attraction of the molecules in a liquid to each other
2
Q
What are alveoli?
A
Small sacs where gas collects and diffuses into the blood during inhalation - lined with fluid (these molecules pull together due to surface tension - attempting to collapse the space in alveoli)
3
Q
What is surfactant?
A
Fluid produced by type II alveolar cells containing proteins and fats - reduces surface tension of the fluid in the lungs
4
Q
What is the result of surfactant?
A
Maximises surface area of the alveoli
Reduces force needed to expand alveoli
Thus surfactant increases lung compliance
5
Q
When do type II alveolar cells start producing surfactant?
A
Between 24 and 34 weeks gestation
6
Q
What helps clear fluid from the lungs at birth?
A
Thorax is squeezed as it passes through vagina
7
Q
What is relseased by the neonate in response to the stress of labour?
A
Adrenalin and cortisol (stimulates respiratory effort)
8
Q
Why does the foramen ovale close at birth? What does it become?
A
First breath expands alveoli - decreased pulmonary vascular resistance causing fall in pressure in the right atrium
Left atrial pressure is now higher than gith which causes closure of foramen ovale - this becomes the fossa ovalis
9
Q
Why does the ductus arteriosus close at birth?
A
Prostaglandins required to keep ductus arteriosus open and increased blood oxygen cause these to drop - resulting in closure of the ductus arteriosus which becomes the ligamentum arteriosum
10
Q
Why does the ductus venosus stop functioning after birth?
A
Umbilical cord is clamped and there is no blood flow in the umbilical veins - this structurally closes and becomes the ligamentum venosum
11
Q
What is the result of hypoxia during labour and birth?
A
Bradycardia
Reduced consciousness
Drop in respiratory effort
Extended hypoxia = hypoxic-ischaemic encephalopathy (HIE) - potentially cerebral palsy
12
Q
What are some issues in neonatal resuscitation?
A
Babies have large surface area to weight ratio (get cold easily)
Babies are born wet so lose heat rapidly
Babies which are born through meconium may have it in mouth / airway
13
Q
What are the principles of neonatal resuscitation?
A
Warm baby
Calculate APGAR score
Stimulate breathing
Inflation breaths
Chest compressions
14
Q
How to warm the baby?
A
Get baby dry (vigorous drying helps stimulate breathing)
Keep warm under heat lamp
Babies under 28 weeks are placed in a plastic bag whilst wet and managed under heat lamp
15
Q
When and how is the APGAR score calculated?
A
1, 5 and 20 minutes whilst resuscitation continues (used as an indicator of progress)
Lowest score is 0 and highest is 10
16
Q
How to stimulate the baby to breath?
A
Vigorous drying
Place head in neutral position to keep airway open (towel under shoulders can help)
If gasping then check for airway obstruction (meconium) and consider aspiration
17
Q
When are inflation breaths given?
A
When neonate is gasping or not breathing despite adequate initial stimulation
18
Q
How are inflation breaths given?
A
2 cycles of 5 inflation breaths (lasting 3 seconds)
If no response then 30 seconds of ventilation breaths
In no response then chest compressions (coordinated with ventilation breaths)
19
Q
What should be used when performing inflation breaths in term/near term babies or pre-term babies?
A
Term = Air
Pre-term = air and oxygen (aim for gradual rise in sats not exceeding 95%)
20
Q
How to perform chest compressions?
A
Start chest compressions if heart rate below 60bpm despite resus and inflation breaths
Performed at 3:1 ratio with ventilation breaths
21
Q
What should be given in severe situations during neonatal resus?
A
IV drugs and intubation
22
Q
What may babies with hypoxic-ischaemic encephalopathy (HIE) benefit from?
A
Therapeutic hypothermia with active cooling (must have gestational age >= 36 weeks and weight greater than 1800g)
23
Q
Outline A-E assessment in a child?
A
Assessments
Airway and breathing = effort of breathing, RR and rhythm, stridor and wheeze, auscultation, skin colour
Breathing = HR, BP, cap refil, skin temp
Disability = Conscious, pupils, BM
Exposure = fever, rash, brusing
Interventions
Airway =
- “head tilt chin lift” (neutral in infant, sniffing in child)
- Naso-pharyngeal airways
Breathing =
- High flow oxygen (15 litres / min) - oxygen mask with reservoir bag
- Intubation and ventilation
Circulation =
- 20ml/kg bolus of 0.9% sodium chloride (in DKA 1-ml/kg due to risk of cerebral oedema)
Disability =
- AVPU (alert, voice, pain, unresponsive)
- If P or U consider intuvation
- Hypoglycaemia = 2ml/kg 10% glucose IV or IO followed by glucose infusion
24
Q
Complete the following table:
A
25
What is placental transfusion?
Blood from the **umbilical cord** entering the circulation of the body
26
What are the benefits of **delayed cord clamping**?
Improved **haemoglobin**
**Iron stores**
**Blood pressure**
Reduction in **intraventricular haemorrhage**
Reduction in **necrotising enterocolitis**
27
What is an apparent **negative effect** of **delayed cord clamping**?
**Neonatal jaundice** (requiring more phototherapy)
28
How long should the delay in cord clamping be?
**1 minute** (clamped sppner in those that need resus)
29
What is the **care for neonates** immediately **after birth**?
**Skin to skin**
**Clamp** **umbilical** cord
**Dry** baby
Keep **warm in hat and blankets**
**Vit K**
**Label baby**
**Measure weight** and length
30
Why and how are babies given vitamin K?
Babies are **deficient**
**IM** injection in the **thigh**
31
Why is **vitamin K** given after birth?
Prevents **bleeding**: intracranial, from umbilical stump and GI bleeding
32
How else may vitamin K be given?
Orally - longer to act and requires **doses at birth, 7 days and 6 weeks**
33
Why is **skin to skin contact important**?
Helps warm baby
Improves mother and baby interaction
Calms baby
Improves breast feeding
34
What forms **part of management** once **mum and baby are out of delivery room**?
**Initiate breast / bottle feeding** when baby is alert enough
**First bath** (can wait days if needed)
**Newborn examination** within 72 hours
**Blood spot test**
Newborn **hearing test**
35
When is the **blood spot screening test** performed on newborns?
**Day 5 or 8** at latest **after consent from parent**
36
What does the blood spoot screening test look for?
9 congenital conditions:
**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**
37
How long do results from the **blood spot screening test** take to come back?
6-8 weeks
38
When is a **newborn examination performed**?
**72 hours after birth** and **repeated at 6-8 weeks**
39
What are the **principles** of the **newborn examination**?
Wash hands **before and after**
**Explain and reassure to parents**
Keep **baby warm**
Start from **head and work to toes**
Ask:
* Has the baby passed **meconium**
* Is the baby **feeding ok**?
* **FH** of **congenital heart, eye or hip problems**
40
How to measure **oxygen saturations** in **newborn examination****?**
Pre-ductal and post-ductal oxygen sats checked (before and after **ductus arteriosus**)
**Normal sats are \>96%** (with difference of no more than 2% - if abnormal then potential admission)
41
Where is the **ductus arteriosus and what is its function**?
**Arch of the aorta** (connects aorta with pulmonary artery)
Normally stops functioning after 1-3 days of birth
Allows blood from deoxygenated right side of the circulation to mix with oxygenated left sided circulation
42
Why is the **ductus arteriosus** important?
Certain heart conditions are **duct-dependent** meaning they rely on the **mixing of blood** across the **ductus arteriosus** - when it closes there can be rapid deterioration of symptoms
43
Where are **pre-ductal saturations** measured?
Babies **right hand** (this recieves blood from the **right subclavian artery** a branch of the **brachiocephalic artery** which branches from the aorta before the ductus arteriosus
44
Where are **post-ductal saturations** measured?
Either **foot** (these recieve blood from the descending aorta - **occuring after the ductus arteriosus**)
45
What to look for in the **general appearance** of a neonate?
Colour (pink is good)
Tone
Cry
46
What should be looked for on the **head** examination of a newborn?
**General appearance**: size, shape, **dysmorphology**, **caput succedaneum**, **cephalohaematoma**, and any **facial injury**
**Head circumference** (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, asymmetry
**Eyes**: slight **squits** are normal, epicanthic folds can indicate Down's, purulent discharge = infection
**Red reflex**: using an **opthalmoscope** - check for symmetry (more pale in dark skinned babies) - absent in **congenital cataracts** and **retinoblastoma**
**Mouth** - cleft lip or tongue tie
**Put little finger in mouth** to check **suckling reflect** and feel the **palate** for **cleft palate**
47
What to examine on a **newborns** shoulders and arms?
**Shoulder symmetry**: check for clavicle fracture
**Arm movement**: check for Erbs palsy
**Brachial pulses**
**Radial pulses**
**Palmar creases**: single crease = Down's but may be normal
**Digits:** check number and if they are straight or curved (**clinodactyly**)
Use a **sats probe** on the right wrist for **pre-ductal readin****g**
48
What to examine on **chest** of a newborn baby?
**Oxygen sats** - right wrist and feet - above 95% is normal
**Observe breathing** - respiratory distress, symmetry and listen for stridor
**Heart sounds** - look for murmurs, heart sounds, HR and identify which side the heart is on
**Breath sounds** - listen for symmetry, good air entry and added sounds
49
What to look for in the **abdomen** on a newborn examination?
**Observe the shape**: concave may be **diaphragmatic hernia** with abdo contents in chest
**Umbilical stump**: look for discharge, infection and periumbilical hernia
**Palpate**: for organomegaly, hernias or masses
50
What to look for in the **genitals** in a newborn examination?
**Observe** for the sex, ambiguity and obvious abnormalities
**Palpate testes and scrotum** - check both present and descended, check for hernias / hydrocoeles
**Inspect penis** for hypospadias, epispadias and urination
**Inspect anus** to check its patent
**Ask about meconium** and whether baby has opened bowels
51
What to look for in the **legs** for a **newborn examination**?
**Observe legs and hips** for equal movements, skin creases, tone and talipes
**Barlows and ortolani manoeuvres** for clunking, clicking and dislocation of the hips
**Count the toes**
52
What to look for in the **back** for a **newborn examination**?
**Inspect and palpate the spine** for curvature, spina bifida and pilonidal sinus
53
What to look for on **reflexes** for **newborn examination**?
**Moro reflex**: rapidly tipped back then arms and legs will extend
**Suckling reflex**
**Rooting reflex**: ticking cheek causes them to turn to stimulus
**Grasp reflex**: place a finger in palm causes grasp
**Stepping reflex**: when held upright and feet touch a surface they make a stepping motion
54
What to look for on **skin** on **newborn examination?**
**Haemangiomas**
**Port wine** stains
**Mongolian blue** spot
**Cradle cap**
**Desquamation**
**Erythema toxicum**
**Milia**
**Acne**
Naevus simplex (“**stork bite**”)
**Moles**
Transient **pustular melanosis**
55
What are **talipes**?
Clubfoot = ankle is in a **supinated position** rolled inwards (can be **positional** or **structural**)
56
What is the difference between **positional** and **structural** talipes?
**Positional** = muscles are tights, bones unaffected - foot can move into normal position (requires physio)
**Structural** = involves bones and requires referral to orthopaedic surgeon
57
Do **skin findings** on newborn examination require action?
No - many will fade with time
58
Do **haemangiomas** on newborns require treatment?
Only when **near the eyes, mouth** or affecting the airway - requires treatment with **beta blockers** i.e. **propanolol** (otherwise monitor and usually resolve with time)
59
What are **port wine stains**?
Pink patches of skin, often on the face, caused by **abnormalities affecting the capillaries** - don't fade with time and turn a **darker red** / **purple** colour
60
What can **port wine stains** be related to?
**Sturge-Weber syndrome** with visual impairment, learning difficulties, headaches, epilepsy and glaucoma
61
What is the **management** of clunky / clicky hips?
Referral for a **hip ultrasound** to rule out **developmental dysplasia of the hips**
62
What do **cephalohaematomas** require monitoring for?
Jaundice and anaemia
63
What do **bony injuries** in newborn examination require?
X-ray to look for fractures (e.g. clavicular fracture)
64
How to manage **soft systolic murmurs** in newborns?
**Grade 2 or less** require monitoring as these often resolve after 24 or 48 hours (may be caused by a patent foramen ovale which closes shortly after birth)
65
How to manage **suspicion of heart failure** / congenital heart disease?
Referral to cardiology for an ECG and echocardiogram
If unwell then **admit to neonatal unit** and **immediate management**
66
How to **complete** a **newborn examination**?
**Discuss 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) and in the baby's **red book**
Explain, reassure and answer any questions with the parents
Arrange **referrals** and **followup** if required
67
What is **caput succedaneum**?
**Oedema** collecting in the scalp **outside of the periosteum** caused by pressure to a specific area of the scalp during prolonged or instrumental delivery
68
What is the periosteum?
Layer of **dense connective tissue** outside the skin (doesnt cross the sutures)
69
Does caput succedaneum require any treatment?
No treatment and **resolves in a few days**
70
What is a **cephalohaematoma**?
Collection of **blood** between the periosteum and the skull
71
When does a **cephalohaematoma** occur?
Traumatic, prolonged or instrumental delivery (described as **traumatic subperiosteal haematoma**)
72
Why does the blood not cross the suture line in cephalohaematoma?
Blood is **below the periosteum**
73
What is the management of cephalohaematoma?
**No intervention** and resolves in a few months
Monitored for **anaemia** and **jaundice** due to blood which collects in the haematoma (breaking down to bilirubin)
74
When can **facial paralysis** occur in childbirth?
During **forceps delivery** - function normally returns spontaneously in a few months - if not then neurosurgical input required
75
When can **Erb's palsy** occur in childbirth?
Injury to the **C5/C6 nerves** in the brachial plexus
76
What is Erb's palsy associated with?
Shoulder dystocia
Traumatic / instrumental delivery
Large birth weight
77
What does **damaged C5/C6 nerves** present as?
Weakness of:
**Shoulder abduction**
**External rotation**
**Arm flexion**
**Finger extension**
Leaving arm having a "waiters tip"
78
What is the treatment of Erb's palsy after birth?
**Function normally returns spontaneously** within a few month (if not then require neurosurgical input)
79
What is a **fractured clavicle** during childbirth associated with?
**Shoulder dystocia**
**Traumatic** delivery
**Instrumental** delivery
**Large** birth weight
80
How can a **fractured clavicle** be picked up on during newborn examination?
Noticable **lack of movement / asymmetry**
Asymmetry of the shoulders with **affected shoulder lower than normal**
**Pain** on **movement** of the arm
81
How can a fractured clavicle be confirmed?
Ultrasound / X-ray
82
What is the management of a fractured clavicle?
Conservative with **immobilisation of the affected arm**
83
What is the main complication of a fractured clavicle?
**Injury to the brachial plexus** with a subsequent nerve palsy
84
What **organisms** commonly cause **neonatal sepsis**?
Group B streptococcus (**GBS**)
Escherichia coli (**e. coli**)
**Listeria**
**Klebsiella**
**Staphylococcus aureus**
85
What are the risk factors of **neonatal sepsis**?
Vaginal **GBS colonisation**
**GBS** sepsis in a **previous baby**
**Maternal sepsis**, **chorioamnionitis or fever \> 38C**
**Prematurity** (less than 37 weeks)
Early (premature) rupture of membrane
Prolonged rupture of membrane (PROM)
86
What are the clinical features of neonatal sepsis?
**Fever**
**Reduced tone** and activity
**Poor feeding**
**Respiratory distress** or apnoea
**Vomiting**
**Tachycardia** or bradycardia
**Hypoxia**
**Jaundice within 24 hours**
**Seizures**
**Hypoglycaemia**
87
What are the **red flags** of **neonatal sepsis**?
**Suspected sepsis** in **mother**
Signs of s**hock**
**Seizures**
Term baby needing **mechanical ventilation**
Respiratory distress starting **more than 4 hours** after birth
Presumed **sepsis** in another baby in a **multiple pregnancy**
88
What is the **management** of **neonatal sepsis**?
If **one risk factor / clinical features** then observe for 12 hours
If **two or more risk factors / clinical features** then **start abx**
**Abx** if single red flag (**within 1 hour of decision**)
**Blood cultures** should be taken before
Check baseline **FBC** and **CRP**
**Lumbar puncture** if features of **meningitis** (e.g. seizures)
89
What are the **antibiotic choice** in **neonatal sepsis**?
**Benzylpenicillin** and **gentamycin** as first line
3rd gen cephalosporin (e.g. **cefotaxime**) may be given as alternative in **lower risk babies**
90
What is the **ongoing management** of **neonatal sepsis**?
**Check CRP** again at **24 hours** and check **blood culture results at 36 hours**
STOP treatment IF **clinically well, blood cultures** are **negative** **36 hours** after taking them and **both CRP** **are less than 10**
**Check CRP after 5 days** if still on treatment and **stop** if: **clinically well**, **lumbar puncture and blood cultures**are negative and **CRP has returned to normal**
91
When to consider a **lumbar puncture** in neonatal sepsis?
Any of CRP results are **more than 10**
92
When does **hypoxic ischaemic encephalopathy** occur?
**In neonates** as a **result** of **hypoxia during birth**
93
What can result from HIE?
**Cerebral palsy**
94
When to suspect HIE?
Events which could lead to hypoxia
**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**
95
What are some causes of HIE?
**Maternal shock**
**Intrapartum haemorrhage**
**Prolapsed cord**
**Nuchal cord** (cord is wrapped around the neck of the baby)
96
What is the **Sarnat staging system** for HIE?
97
What is the **management** of **HIE**?
Coordinated by **specialists** in neonatology
**Supportive** - resus, ventilation, circulatory support, nutrition, acid base balance and treatment of seizures
**Therapeutic hypothermia** - is a option to help protect brain from hypoxic injury
**Follow up** from paediatrician and **multidisciplinary team** - for assessing development
98
How does **therapeutic hypothermia** work?
In **neonatal ICU** baby is **actively cooled** with cooling blankets and cooling hat - target temp of **33 and 34C** measured with **rectal probe** - continued for **72 hours** after baby is warmed to normal temp over **6 hours**
Intention is to **reduce inglammation and neurone loss** after the acute hypoxic injury
Reduces risk of cerebral palsy, developmental delay, learning disability, blindness and death
99
How is **conjugated bilirubin** excreted?
Via the **biliary system** into GI tract and via the **urine**
100
Why does **physiological jaundice** happen?
High conc of RBCs in **fetus and neonate** (these are fragile)
Normally **bilirubin** is excreted via the placenta - thus at birth there is a risk in bilirubin causing yellow skin for 2-7 days (normally **resolves by 10 days**)
The fetus also have **less developed liver function** at birth
101
What are the **causes of neonatal jaundice** (increased production of bilirubin or decreased clearance of bilirubin)
**Increased production**:
* **Haemolytic disease of the newborn**
* **ABO** incompatibility
* **Haemorrhage**
* **Intraventricular haemorrhage**
* **Cephalo-haematoma**
* **Polycythaemia**
* **Sepsis** and DIC
* **G6PD** deficiency
**Decreased clearance**:
* **Prematurity**
* **Breast milk** jaundice
* **Neonatal cholestasis**
* **Extrahepatic biliary atresia**
* **Endocrine disorders** (hypothyroid and hypopituitary)
* **Gilbert** syndrome
102
What is **jaundice in the first 24 hours of life**?
**Pathological** - urgent investiation - **neonatal sepsis** is a common cause
103
Why is **jaundice in premature neonates** more concerning?
Due to **immature liver** there may be **more bilirubin** increasing risk of **kernicterus** which is **brain damage due to high bilirubin levels**
104
Why are **babies** that are **breast fed** more likely to have **neonatal jaundice**?
- 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
- Inadequate breastfeeding may lead to **slow passage of stools** increasing absorption of bilirubin in the intestines
105
What is **haemolytic disease of the newborn**?
Cause of **haemolysis** and **jaundice** in the neonate
Caused by **incompatibility** between **rhesus antigens** on the surface of the **RBCs** of the mother and fetus
106
How does **haemolytic disease of the newborn** occur?
Woman who is **rhesus D negative** gives birth to a **rhesus D positive** baby and is exposed to fetal blood (becomes **sensitized**) - woman then develops **antibodies** to the rhesus D antigen - when the woman becomes pregnant again the mothers **anti-D antibodies** can cross the placenta causing **haemolysis**, **anaemia** and **high bilirubin levels**
107
What is **prolonged jaundice**?
**More than 14 days** in **full term babies**
**More than 21 days** in **premature babies**
108
What can cause prolonged jaundice?
**Biliary atresia**
**Hypothyroidism**
**G6PD deficiency**
109
What are the **investigations** for **neonatal jaundice**?
**FBC** and **blood film** for polycythaemia or anaemia
**Conjugated bilirubin** - elevated levels indicates 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 abx)
**Glucose-6-phosphate-dehydrogenase** (GDPD) levels for G6PD deficiency
110
What is the management of jaundiced neonates?
Total bilirubin levels are monitored and **plotted on treatment threshold charts** (specific for gestational age of baby) - if bilirubin levels exceed threshold levels then need to be **commenced on treatment**
111
What are the **treatment** options for **neonatal jaundice**?
**Phototherapy**
**Exchange transfusion** (for extremely high levels) - removing blood from neonate and replacing with donor blood
112
How is **phototherapy** used to treat **neonatal jaundice**?
Converts **unconjugated bilirubin** into **isomers** which can be excreted in the bile and urine **without requiring conjugation in the liver**
Baby is placed into a **light box which shines UV light** - with only nappy and eye patches on
**Rebound bilirubin** taken 12-18 hours after stopping
113
How does **Kernicterus** (a type of brain damage) occur?
**Excessive bilirubin levels** can cause damage to the CNS (as it can **cross the blood-brain barrier**)
114
What can **kernicterus** cause?
**Cerebral palsy**
**Learning disability**
**Deafness**
115
What is **prematurity?**
Birth before 37 weeks
116
When should resuscutation be carefully considered?
**Under 500 grams** and **before 24 weeks**
117
What are **prematurity** levels?
**Extreme preterm** = under 28 weeks
**Very preterm** = 28-32 weeks
**Moderate to late preterm** = 32-37 weeks
118
What are some **association** with prematurity?
**Social deprivation**
**Smoking**
**Alcohol**
**Drugs**
**Overweight or underweight mother**
**Maternal co-morbidities**
**Twins**
**Personal or family history** of prematurity
119
When should **delaying birth** be considered?
Women with a **history of preterm birth**
Ultrasound demonstrating a **cervical length** of **25mm or less before 24 weeks gestation**
120
How can **birth be delayed**?
**Prophylactic vaginal progesterone** (progesterone suppository in the vagina)
**Prophylactic cervical cerclage** (putting a suture in the cervix to hold it closed)
121
What **methods** to **improve the outcome** in preterm labour?
**Tocolysis** with **nifedipine** (a CCB which suppresses labour)
**Maternal corticosteroids** (before 35 weeks gestation to reduce neonatal morbidity and mortality)
**IV magnesium sulphate** (offered before 34 weeks gestation and helps protect the baby's brain)
**Delayed cord clamping or milking** to increase circulating blood volume and haemoglobin in the baby
122
What **issues in early life** does **prematurity** cause?
**Respiratory distress syndrome**
**Hypothermia**
**Hypoglycaemia**
**Poor feeding**
**Apnoea and bradycardia**
**Neonatal jaundice**
**Intraventricular haemorrhage**
**Retinopathy** of prematurity
**Necrotising enterocolitis**
**Immature immune system** and infection
123
What are the **long term effects** of prematurity?
Chronic lung disease of prematurity (**CLDP**)
**Learning and behavioural difficulties**
**Susceptibility to infections**, particularly respiratory tract infections
**Hearing and visual impairment**
**Cerebral palsy**
124
What are apnoeas?
Defined as periods when **breathing stops** spontaneously for **more than 20 seconds** or **shorter periods with oxygen desaturation** or **bradycardia**
125
When are **apnoeas** most common?
**Premature neonates** - all babies less than 28 weeks gestation
126
What is the cause of apnoeas?
**Immaturity** of the **autonomic nervous system** which controls respiration and heart rate
127
What are the **causes of apnoeas**?
**Infection**
**Anaemia**
**Airway obstruction** (may be positional)
**CNS pathology**, such as seizures or haemorrhage
**Gastro-oesophageal reflux**
**Neonatal abstinence** syndrome
128
What is the **management** of **apnoeas**?
- Attach apnoea monitor (make a sound when apnoea is occuring)
- **Tactile stimulation** to prompt rebreathing
- **IV caffeine** to prevent apnoea and bradycardia
- Episodes will settle with time
129
Who does retinopathy of prematurity affect?
Preterm (before 32 weeks)
Low birth weight
130
What can abnormal development of blood vessels in the retina cause?
**Scarring**
**Retinal detachment**
**Blindness** (treatment can prevent this - screening is **_important_**)
131
When is **retinal blood vessel development**?
From 16 to 37/40 weeks (grow from middle of retina outwards)
132
What is **retinal vessel formation** stimulated by?
**Hypoxia** - normal condition in the retina (in preterm babies this stimulant is removed)
133
What happens when **hypoxia** returns in **retina of preterm**?
Response of **excessive blood vessels** (neovascularisation) as well as scar tissue - can cause **retinal detachment**
134
What are the **three zones of the retina**?
**Zone 1** = optic nerve + macula
**Zone 2** = the **edge of zone 1 to the ora serrata**, the **pigmented boarder between the retina and ciliary** body
**Zone 3** = outside the ora serrata
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How are the retinal areas described?
Clock face = disease from 3 o'clock to 5 o'clock
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How are the areas of disease in retinopathy of prematurity described?
**Stage 1** (slightly abnormal vessel growth) to **stage 5** (complete retinal detachment)
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What is "**plus disease**" on retinopathy of prematurity?
Additional findings such as **tortuous vessels** and **hazy vitreous** **humour**
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Which babies should be screened for ROP?
Born before 32 weeks or under 1.5kg
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When should screening for ROP be performed?
**30 – 31 weeks gestational age** in babies born **before 27 weeks**
**4 – 5 weeks of age** in babies **born after 27 weeks**
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How often should screening for ROP occur?
Every 2 weeks and **cease when retinal vessels enter zone 3** (usually around 36 weeks gestation)
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What is the treatment of ROP?
**Stop new blood vessels developing**:
- First line **transpupillary laser photocoagulation** to hald and reverse **neovascularisation**
- **Cyrotherapy** and injections of intravitreal VEGF inhibitors
- **Surgery** if retinal detachment occurs
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Who does **respiratory distress syndrome** affect?
**Premature neonates** - born before the lungs start producing adequate surfactant (usually below 32 weeks)
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What does an X-ray show for respiratory distress syndrome?
**Ground glass** appearance
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What is the **pathophysiology** in **respiratory distress syndrome**?
**Inadequate surfactant** causing **high surface tension** in **alveoli** resulting in **hypoxia**, **hypercapnia** (high CO2) and **respiratory distress**
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What is the **prevention** of **respiratory distress syndrome**?
**Antenatal steriods** (i.e. **dexamethasone**) given to mothers with suspected preterm labour to increase production of **surfactant**
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What is the **management** of **respiratory distress syndrome**?
**Intubation and ventilation** - fully assist breathing if respiratory distress is severe
**Endotracheal surfactant** - artificial surfactant delivered into lungs via **endotracheal tube**
**Continuous positive airway pressure** (CPAP) via nasal mask to keep lungs inflates
**Supplementary oxygen** - to maintain O2 sats in preterm babies to 91-95%
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What are some **short term complication** of respiratory distress syndrome?
**Pneumothorax**
**Infection**
**Apnoea**
**Intraventricular haemorrhage**
**Pulmonary haemorrhage**
**Necrotising enterocolitis**
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What are some **long term complications** of respiratory distress?
**Chronic lung disease of prematurity**
**Retinopathy of prematurity** - more often and severely in neonates with RDS
**Neurological**, **hearing** and **visual** impairment
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What is **nectrotising enterocolitis** (NEC)?
Disorder affecting **premature neonates** where **part of the bowel becomes necrotic** - life threatening
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Why is NEC life-threatening?
Risk of **perforation** and **peritonitis** and **shock**
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What are the **risk factors** for developing NEC?
- **Low birth weight** or very premature
- **Formula feeds** (less common in babies feb by breast milk feeds)
- **Respiratory distress** and assisted ventilation
- **Sepsis**
- **Patent ductus arteriosus** and other congenital heart disease
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How does NEC present?
**Intolerance** to **feeds**
**Vomiting**, particularly with **green bile**
Generally **unwell**
Distended, **tender abdomen**
**Absent bowel sounds**
**Blood** in **stools**
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What **investigations** for **NEC**?
**Blood tests** - FBC (thrombocytopenia and neutropenia), CRP (inflammation), capillary blood gas (metabolic acidosis), blood culture for sepsis
**Abominal x-ray** - for diagnosis in **supine** position and **lateral** (on side with patient on back) or **lateral decubitus** (from side with neonate on side)
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What do **abdo x-rays** with NEC show?
**Dilated** loops of **bowel**
**Bowel wall oedema** (thickened bowel wall)
**Pneumatosis intestinalis** (gas in the bowel wall and a sign of NEC)
**Pneumoperitoneum** (free gas in peritoneal cavity, indicates perforation)
**Gas in the portal veins**
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What is the **management** of **NEC**?
**Nil by mouth**
**IV fluids**
**Total parenteral nutrition** (TPN)
**Abx** (to stabalise)
**NG tube** to drain fluid and gas from stomach
**NEC** is a **surgical emergency** - immediate referral to neonatal surgical team - remove the dead bowel tissue (may have **temporary stoma**)
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What are the **complications** of **NEC**?
- Perforation and peritonitis
- Sepsis
- Death
- Strictures
- Abscess formation
- Recurrence
- Long term stoma
**- Short bowel syndrome** after surgery
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What is neonatal abstinence syndrome (**NAS**)
Withdrawal symptoms which happen in **neonates** of **mothers** which used **substances** in pregnancy - **symptoms and management** is different depending on substance used in pregnancy
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Which **substances** can cause **NAS**?
- Opiates
- Methadone
- Benzodiazepines
- Cocaine
- Amphetamines
- Nicotine or cannabis
- Alcohol
- SSRI antidepressants
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How long does withdrawal take to become apparent?
**Most opiates, diazepam, SSRIs, alcohol** = 3-72 hours after birth
**From methadone and other benzos** = 24 hours to 21 days
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What are the **CNS symptoms** of **NAS**?
**Irritability**
**Increased tone**
**High pitched cry**
**Not settling**
**Tremors**
**Seizures**
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What are the **vasomotor** and **respiratory** symptoms of **NAS**?
Yawning
Sweating
Unstable temperature and pyrexia
Tachypnoea (fast breathing)
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What are the **matabolic** and **gastrointestinal** symptoms of NAS?
Poor feeding
Regurgitation or vomiting
Hypoglycaemia
Loose stoold with a sore nappy area
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What is the **management** of **NAS**?
- If **mother known** to use substances then have an **alert on notes** so neonate = **extra monitoring**
- Babies kept in with **monitoring on NAS chart** for at least 2 days (48 hours for SSRI dependance)
- **Urine sample** can be collected
- Neonate supported in a **quiet and dim environment** with gentle handling and comforting
- Medical treatment
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What is the **medical treatment** for moderate to severe symptoms?
- Oral **morphine sulphate** for **opiate** withdrawal
- Oral **phenobarbitone** for non-opiate withdrawal
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What is the treatment for SSRI withdrawal?
No medical treatment usually required
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What are the **additional management steps** in **NAS**?
Test for **hep B** and **C** and **HIV**
**Safeguarding** and **social service involvement**
**Safety-net advice** for readmission if withdrawl signs / symptoms occur
**Follow up from paediatrics**, **social services**, **health visitors** and **the GP**
**Support for the mother** to stop using substances
Check for the **suitability for breastfeeding** in mothers with substance abuse
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When are the effects of drink in alcohol greatest in pregnancy?
**First 3 months of pregnancy**
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What can **alcohol** in **early pregnancy** lead to?
Miscarriage
Small for dates
Preterm delivery
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What is **fetal alcohol syndrome**?
Effects and characteristics:
- **Microcephaly** (small head)
- **Thin upper lip**
- **Smooth flat philtrum** (groove between nose and upper lip)
- **Short palpebral fissure**
- Learning disability
- Behavioural difficulties
- Hearing and vision problems
- Cerebral palsy
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What is **congenital rubella syndrome** caused by?
**Maternal infection** with the rubella virus during pregnancy (highest risk in first 3 months)
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How to prevent congenital rubella syndrome?
Women **planning to become pregnant** should **have the MMR vaccine** - if in doubt rubella immunity can be tested for - if no antibodies then **vaccinates** with **2 doses** of the **MMR 3 months apart**
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Should **pregnant women** **recieve the MMR vaccine**?
No - this is a **live vaccine** (non-immune should be given vaccine **after birth**)
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What are the features of **congenital rubella syndrome**?
- **Congenital cataracts**
- Congenital **heart disease** (PDA and pulmonary stenosis)
- **Learning disability**
- **Hearing loss**
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What is chicken pox caused by?
**Varicella zoster virus** (VZV)
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Why is **chicken pox dangerous in pregnancy**?
Causes **more severe cases in mother** such as varicella **penumonitis, hepatitis** or **encephalitis**
**Fetal varicella syndrome**
Severe **neonatal varicella infection** if mum is infected around delivery
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What is the **prevention of chickenpox in pregnancy**?
**IgG** levels for **VZV** can be tested and if not immune the **offered the varicella vaccine before or after pregnancy**
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How to **manage exposure to chickenpox in pregnancy**?
- If had previous chickenpox then safe
- If not sure then test VZV IgG levels
- If **not immune** then treated with **IV varicella immunoglobulins** as prophylaxis against developing chickenpox (given **within 10 days** of exposure)
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How to **treat chickenpox rash**?
**Oral aciclovir** if present within 24 hours and **more than 20 weeks gestation**
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What are the **typical features** of **congenital varicella syndrome**?
Fetal growth restriction
Microcephaly, hydrocephalus and learning disability
Scars and significatn skin changes following the **dermatomes**
Limb **hypoplasia** (underdeveloped limbs)
Cataracts and inflammation in the eye (**chorioretinitis**)
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How often does **congenital varicella syndrome** occur?
1% of cases of chickenpox in pregnancy - when there is infection in first 28 weeks
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What does **congenital cytomegalovirus** occur?
Maternal CMV infection during preganancy
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How is CMV spread?
In the **infected saliva or urine** of asymptomatic children
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Is congenital CMV common?
No - most cases of CMV in preganancy don't cause congenital CMV
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What are the features of congenital CMV?
- Fetal growth restriction
- Microcephaly
- Hearing loss
- Vision loss
- Learning disability
- Seizures
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What causes congenital toxoplasmosis?
**Infection** with the **toxoplasma gondii** parasite during pregnancy
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How is **T****oxoplasmosis gondii** spread?
Contamination with faeces from cat that is a **host** **of the parasite**
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What is the **classic triad** of features of toxoplasmosis?
- Intracranial calcification
- Hydrocephalus
- Chorioretinitis
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How is **congenital zika virus** spread?
By **host Aedes mosquitos** in areas of the world where its prevant
Having **sex with** someone infected with the virus
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What are the symptoms of infection with zika virus, what does it cause in pregnancy?
No symptoms to a **mild flu like illness**
## Footnote
**Congenital Zika syndrome**
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What are the **features of congenital zika syndrome**?
**Microcephaly**
**Fetal growth restriction**
Other intracranial abnormalities - **ventriculomegaly**, **cerebellar atrophy**
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What is the management of zika virus in pregnancy?
Testing for: **viral PCR**, **antibodies to the Zika virus**
**Referral to fetal medicine** to monitor pregnancy
**No treatment for virus**
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What is **sudden infant death syndrom****e** (SIDS)?
Sudden unexplained death in an infant - aka **cot death** - usually occuring in **first 6 months of life**
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What are the **risk factors** for **SIDS**?
**Premature**
**Low birth weight**
**Smoking during pregnancy**
**Male baby** (only slightly increased risk)
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How to **minimise the risk of SIDS**?
- **Put baby on back** when unsupervised
- Keep **head uncovered**
- Place **feet at end of bed** to prevent sliding under blanket
- Keep **cot clear of toys** / blankets
- Comfortable room temp (**16-20C**)
- **Avoid smoking** or handling after smoking
- **Avoid co-sleeping**, particularly on sofa
- If co-sleeping **avoid alcohol, drugs, smoking, sleeping tablets or deep sleepers**
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How to counsel patient on SIDS?
Empathise - don't imply blame - discuss **reducing risk**
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What is the **support** for patients affected by SIDS?
**Lullaby trust** - charity to help support families - bereavement counselling shoud be available
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What support do patients who have been affected by SIDS get for next child?
**CONI** - **care of next infant team** help with next infant - providing extra support and **home visits, resus training** and access to equipment such as **movement monitors** which alarm if **baby stops breathing**
