Paeds IV Flashcards

Question

Which babies are screened for ROM? [2] How often does screening occur? [1] What does screening involve? [1]

Answer 1

**All babies < 1500g or 31/40 are screen** **4 – 5 weeks** of age in **babies born after 27 weeks** **Screening** should happen **at least every 2 weeks** and can **cease once the retinal vessels enter zone 3**, usually at around **36 weeks gestation.** **Screening** involves monitoring the **retinal vessels as they develop and looking for plus disease.**

Answer 2

First line is **transpupillary laser photocoagulation** to halt and reverse neovascularisation. Other options are **cryotherapy** and injections of **intravitreal VEGF inhibitors**. **Surgery** (vitrectomy) may be required if **retinal detachment occurs.**

Answer 3

**PDA** **Chronic lung disease of prematurity** **ROM** **Neurodisability**: hearing impairment and oral aversion **Neurodiversity**

Answer 4

**RSV prophylaxis**

Answer 5

**Risk factors:** - exposure to tobacco smoke - late or no antenatal care - young maternal age - premature birth Instruct babies to ''Back to sleep" - sleep on their backs to reduce likelyhood

Answer 6

**A typical presentation of meconium aspiration syndrome (MAS)** may involve a **term or post-term neonate displaying signs of respiratory distress shortly after birth**: **Tachypnoea**: - Rapid breathing is one of the most common presenting features in MAS. It typically occurs within minutes to hours after birth. **Cyanosis**: - A bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. **Decreased breath sounds or rales:** - Auscultation may reveal decreased breath sounds with rales or rhonchi due to airway obstruction by meconium. **Barrel-shaped chest**: - This may be present due to hyperinflation of the lungs from obstructive emphysema as a result of air trapping. **Prolonged expiratory phase:** - This can be noted on physical examination and is indicative of airway obstruction. ## Footnote **NB**: It's important to note that the severity of symptoms and findings can vary significantly between individuals. Some neonates with MAS may present with mild respiratory distress while others may develop severe respiratory failure requiring mechanical ventilation

Answer 7

**First-line investigations** **Chest X-ray**: - A chest radiograph is essential to evaluate the presence of infiltrates, atelectasis, or hyperinflation. Typical findings in meconium aspiration syndrome (MAS) **include patchy areas of atelectasis and hyperinflation**. - The presence of air leaks such as **pneumothorax** or **pneumomediastinum** should also be assessed. **Arterial blood gas (ABG):** - ABG analysis is critical for assessing the degree of **hypoxemia, hypercapnia, and acidosis**. - This helps gauge the **severity of respiratory compromise** and guides o**xygen therapy and ventilation strategies.** **Pulse oximetry:** - **Continuous monitoring of oxygen saturation** provides real-time data on the infant's oxygenation status and helps in titrating supplemental oxygen levels. ## Footnote **NB**: The diagnosis of MAS typically relies heavily on clinical presentation combined with radiographic evidence from chest X-rays. Further investigations are guided by specific clinical indications such as suspected PPHN or concurrent infections.

Answer 8

**Echocardiography**: - This investigation is indicated if there are signs suggestive of persistent pulmonary hypertension of the newborn (PPHN), which can coexist with MAS. **Echocardiography evaluates pulmonary artery pressures, cardiac function, and excludes congenital heart disease.**

Answer 9

**Initial stabilisation:** * Avoid routine intrapartum suctioning. * **If the neonate is vigorous** (strong respiratory effort, good muscle tone, heart rate >100 bpm), proceed with **standard neonatal care.** * **If the neonate is not vigorous**: perform **direct laryngoscopy and tracheal suctioning to remove meconium from the airway before initiating positive pressure ventilation (PPV).** **Respiratory support:** * Administer supplemental oxygen to maintain target oxygen saturation levels as per neonatal resuscitation guidelines. * Initiate continuous positive airway pressure (CPAP) or mechanical ventilation if indicated by respiratory distress or hypoxaemia. **Surfactant therapy:** * Consider administration of exogenous surfactant in cases of severe respiratory distress or when mechanical ventilation is required. **Antibiotic therapy:** * Initiate empirical antibiotic therapy due to the risk of secondary bacterial infection. Adjust based on culture results and clinical course **Management of persistent pulmonary hypertension (PPHN):** * Employ **inhaled nitric oxide (iNO)** for infants with **significant PPHN** **unresponsive to conventional ventilation and oxygen therapy.** * If iNO is unavailable or ineffective, consider extracorporeal membrane oxygenation (**ECMO**) as a last resort in specialised centres. **AVOID routine use of corticosteroids** unless there are specific indications such as concurrent conditions requiring their use.

Answer 10

After first breath: - **decrease** in **pulmonary vascular resistance** causes fall in pressure in **right atrium** At this point: - **the left atrial pressure** is **greater** than the **right atrial pressure**, which **squashes the atrial septum** and **causes functional closure of the foramen ovale**. The foramen ovale then **structurally closes and becomes the fossa ovalis.** **Prostaglandins** are required to keep the **ductus arteriosus open**.: - **Increased blood oxygenation** causes a **drop in circulating prostaglandins.** This causes **closure** of the **ductus arteriosus, which becomes the ligamentum arteriosum**.

Answer 11

During **birth** the **thorax** is **squeezed** as the body passes through the **vagina**, helping to **clear fluid from the lungs** **Birth, temperature change, sound and physical touch stimulate** the baby to **promote the first breath**. - A **strong first breath** is required to **expand** the **previously collapsed alveoli for the first time** **Adrenalin and cortisol** are released in response to the **stress of labour**, **stimulating respiratory effort** The first breaths the **baby takes expands the alveoli**, **decreasing the pulmonary vascular resistance**. The decrease in pulmonary vascular resistance causes a **fall in pressure in the right atrium**

Answer 12

Pulmonary hypoplasia is a term used for newborn infants with underdeveloped lungs Causes include **oligohydramnios** **congenital diaphragmatic hernia**

Answer 13

**Warm The Baby**: - Get the **baby dry as quickly** as possible. **Vigorous** **drying** also helps **stimulate breathing.** - Keep the baby warm with **warm delivery rooms** and **management under a heat lamp** - **Babies under 28 weeks** are placed in a **plastic bag while still wet and managed under a heat lamp** **Calculate the APGAR Score** This is done at **1, 5 and 10 minutes** whilst resuscitation continues This is used as an indicator of the progress over the first minutes after birth * It helps guide neonatal resuscitation efforts **Stimulate Breathing** * Simulate the baby to prompt breathing, for example by **drying vigorously with a towel** * **Place the baby’s head in a neutral position to keep airway open**. A **towel** **under** the **shoulders** can help keep it neutral. * If gasping or unable to breath, **check for airway obstruction (i.e. meconium) and consider aspiration under direct visualisation** **Inflation Breaths** - given when the neonate is gasping or not breathing despite adequate initial simulation. - **Two cycles of five inflation breaths** (**lasting** **3 seconds each**) can be given to **stimulate breathing and heart rate** * If there is **no response and the heart rate is low:** **30 seconds of ventilation breaths** can be used * **If there is still no response**: **chest** **compressions** **can be used**, **coordinated** with the **ventilation breaths** * **Technique is very important** in delivering effective inflation breaths. Get someone experienced to show you how to perform them. It is essential to maintain a neutral head position and get a good seal around the mouth and nose. Look for a rise and fall in the chest. * When performing inflation breaths,** air should be used in term or near term babies**, and a **mix of air and oxygen should be used in pre-term babies**. **Chest Compressions** * **Start** chest compressions if **heart rate remains below 60 bpm** despite resuscitation and inflation breaths (see protocol) * **Chest compressions** are **performed at a 3:1 ratio with ventilation breaths**

Answer 14

**Babies** are **born with a deficiency of vitamin K**: - Vitamin K helps to **prevent bleeding, particularly intracranial, umbilical stump and gastrointestinal bleeding** ## Footnote **NB**: As Vit K is via injection this can have the helpful side effect of stimulating the baby to cry, which helps expand the lungs.

Answer 15

* Caput Succedaneum * Cephalohaematoma * Facial Paralysis * Erbs Palsy * Fractured Clavicle

Answer 16

Damaged to the **C5/C6 nerves** leads to **weakness of shoulder abduction and external rotation, arm flexion and finger extension**. This leads to the affected arm having a “**waiters tip**” appearance: * **Internally rotated shoulder** * **Extended elbow** * **Flexed wrist facing backwards** (pronated) * **Lack of movement in the affected arm**

Answer 17

Function normally **returns spontaneously within a few months**. If function does not return then they may required neurosurgical input.

Answer 18

**Gastrointestinal aetiologies** thought to be due to a disturbance in the gastrointestinal system. Proposed mechanisms leading to infantile colic include: * **Differences in gut microbiome**, particularly alterations in Klebsiella species, anaerobic gram-negative bacteria, Escherichia coli and Lactobacillus species * **Increased intra-luminal gas** due to **unabsorbed carbohydrate fermentation** by colonic bacteria * **Gastrointestinal dysmotility**: notably intestinal hypermotility secondary to autonomic imbalance * **Visceral hypersensitivity:** increase in pain signals from hypersensitive gut visceral pathways **Psychosocial aetiologies** There is an association between certain psychosocial factors in the parents and infantile colic, including: * **Stressful pregnancies and birth** * **Post-partum depression** * **Parental** **anxiety** and depression, even paternal depression during pregnancy * **Lower parental education** and intelligence **Biological aetiologies** * One of the theories that has been studied is that infantile colic may be the early manifestation of **migraine**, although studies have shown inconclusive results regarding this association * **Tobacco smoke and nicotine exposure,** particularly during pregnancy or the post-partum period, is associated with a greater risk of developing infantile colic (twice as common) * **Elevated serotonin levels may play a role in infantile colic**, where some studies have shown that urinary 5-OH IAA concentrations are greater in infants with colic compared to controls

Answer 19

Another important factor in infantile colic is the **absence of red flag symptoms and signs**. Infantile colic is generally a diagnosis of exclusion, as it occurs in an otherwise healthy infant. Usually an organic cause of crying is only found in approximately 10% of patients who present with excessive crying. Red flag features which must be absent include: * Fever * Evidence of diarrhoea, vomiting, abdominal distention * Reduced conscious state e.g. lethargy, drowsiness, floppy * Signs of trauma e.g. bruising, bleeding, fractures * Poor feeding * Poor weight gain and growth * Signs of developmental delay

Answer 20

**Normal crying** **Differences** * Normal crying is **usually** **consolable** by soothing, feeding, burping, or changing nappies (there is usually a discernible cause of crying) * The **crying in infantile colic tends to be louder, more 'screaming' in nature**, of a higher pitch **Intussusception**: **Differences** * **Vomiting** may be present * Infants with intussusception may have diarrhoea, **'red-currant jelly'** like stools or rectal bleeding * The pathognomonic sign is an **elongated mass in the right upper quadrant** **Cow's milk protein allergy** Differences * Usually will have other symptoms such as **vomiting, diarrhoea with blood/mucous, eczema** * May have **poor weight gain and growth** * May have **family history of milk protein allergy also** **Gastro-oesophageal reflux disease** **Differences** * May present with **recurrent regurgitation of feeds after meals**, often effortless and is worse when the infant lying down * May have **poor weight gain and growth** * In severe cases, may have **haematemesis**

Answer 21

**Caregiver education and support** - It is important to educate the caregiver on the benign and **self-limiting nature of the condition**, providing reassurance that the infant is **not unwell and that it will spontaneously resolve by 3-5 months of age** - **Reassure** that is **long term prognosis is excellent** **Distraction techniques** are **excellent** at **helping** **Appropriate feeding techniques** **CBT** and **hypnotherapy** can be useful - **Reduce brain-gut axis that drives it** Dietary changes not helpful.

Answer 22

Both **immediate** (**IgE mediated**) and **delayed** (**non-IgE mediated**) **reactions** are **seen**. - The term **CMPA** is usually used for **immediate** reactions and **CMPI** for **mild-moderate delayed reactions.**

Answer 23

**GI features:** **Diarrhoea**: - This can be chronic and may contain blood or mucus. It is often associated with perianal redness. **Vomiting**: - This is typically regurgitation but can occasionally be projectile in nature. **Abdominal pain**: - Infants may show signs of discomfort such as crying and drawing up their legs. Older children may verbalise this symptom. **Faltering growth or failure to thrive:** - Due to malabsorption and loss of nutrients or decreased intake due to aversion to feeding. **Constipation**: - This can also be a feature, though less common than diarrhoea. ## Footnote **NB**: While immediate IgE-mediated reactions (urticaria, angioedema, vomiting, wheezing) within 2 hours of ingestion are easier to recognise, non-IgE mediated reactions such as those involving the gastrointestinal tract may have a delayed onset up to 48 hours after ingestion making them more difficult to identify. Furthermore, some patients may experience mixed IgE and non-IgE mediated responses.

Answer 24

**Management if formula-fed** * **extensive hydrolysed formula (eHF) milk** is the first-line replacement formula for infants with mild-moderate symptoms * **amino acid-based formula (AAF)** in infants with **severe CMPA** or if no response to eHF * around 10% of infants are also intolerant to soya milk **Management if breast-fed**: * **continue** **breastfeeding** * **eliminate cow's milk protein from maternal diet**. Consider prescribing **calcium** **supplements** for breastfeeding mothers whose babies have, or are suspected to have, CMPI, to prevent deficiency whilst they exclude dairy from their diet * **use eHF milk when breastfeeding stops**, until **12 months of age and at least for 6 months**

Answer 25

**Enterobius vermicularis**, commonly known as threadworms, are small, white parasitic nematodes that primarily inhabit the human gastrointestinal tract.

Answer 26

**Mebendazole** - is recommended as a first-line treatment for all individuals **aged over six months**. A **single** **dose** should be **given**, followed by a **repeat dose after two weeks** if symptoms persist. **Piperazine** **with** **senna** is an alternative for those who cannot tolerate mebendazole or for **pregnant women in their second or third trimester.**

Answer 27

**Hirschsprung-associated enterocolitis (HAEC)** is **inflammation** and **obstruction** of the **intestine** occurring in around **20% of neonates with Hirschsprung’s disease**. - It typically presents **within 2-4 weeks of birth with fever, abdominal distention, diarrhoea (often with blood)** and features of **sepsis**. - It is **life threatening and can lead to toxic megacolon and perforation of the bowel**. It requires **urgent antibiotics, fluid resuscitation and decompression of the obstructed bowel.**

Answer 28

**Investigations** * abdominal x-ray * **rectal biopsy**: gold standard for diagnosis **Management** * initially: **rectal washouts/bowel irrigation** * **definitive management**: **surgery** to affected segment of the colon