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Y4 Neonatology > Sick-term infant > Flashcards

Sick-term infant Flashcards

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1
Q

Define the neonatal period

A

0-27days old

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2
Q

What are the warning signs of a sick infant ?

A
  • Not feeding well
  • Convulsions
  • Drowsy or unconcious
  • Movement only when stimulated or no movement at all
  • Tachypnoea (>= 60)
  • Grunting
  • Accessory muscles used
  • Raised temp >= 38
  • Hypothermia < 35.5
  • Central cyanosis
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3
Q

What is the emergency management of a neonate and the treatment given ?

A
  • ABC - use a nasal cannula if O2 sat ≤ 90%, use bag & mask ventilation if aponea, gasping or RR < 20
  • IV access
  • IV antibiotics - is pyrexia of unknown source give GAM, if suspected menigococcal septicaemia follow meningitis treatment (in preterm lecture)
  • If drowsy or convulsing check BG - give IV glucose if needed
  • If convulsing - 1st line = phenobarbitol, 2nd line = phenytoin
  • Admit & monitor + further investigations if needed
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4
Q

What are the main causes of convulsions or fits in infants ?

A
  • Hypoxic ichaemic encephalopathy (result of perinatal asphyxia)
  • CNS infection e.g. meningitis/ encephalitis
  • Hypoglycaemia
  • Hypocalcaemia
  • Itrancranial haemorrhage
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5
Q

Define what hypoxic ischaemic encephalopathy is

A

This is where the babies O2 supply was interupted at birth, this can then result in neurodevelopmental problems in the future e.g. cerebral palsy

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6
Q

What are the symptoms of hypoxic ischaemic encephalopathy?

A
  • Hyperalert or decreased conciousness
  • Irritable
  • Eye rolling
  • Convulsions/fits
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7
Q

What is the treatment of hypoxic ischaemic encephalopathy?

A

May need mild hypothermia/cooling treatment & need to be admitted to NICU where they may have ventilation or CPAP

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8
Q

Define hypoglycaemia in neonates

A

≤ 2.5

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9
Q

What are the symptoms of hypoglycaemia in neonates ?

A
  • Coma or decreased conciousness
  • Convulsions
  • Transient hypermesis (vomiting)
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10
Q

What is the treatment of hypoglycaemia in neonates ?

A

IV glucose infusion

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11
Q

Define hypocalcaemia in neonates

A

< 2.1 (norm is 2.1-2.6)

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12
Q

What are the symptoms of hypocalcaemia in neonates ?

A
  • Convulsion/fits - muscle spasms
  • Prolonged QT interval
  • Laryngospasm
  • Bronchospasm
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13
Q

What is the treatment of hypocalcaemia in neonates ?

A
  • 1st line = Low PO43- + calcium gluconate
  • If also have hypomagnesaemia the give IV MgSO4
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14
Q

What are the 4 main serious infections in neonates ?

A
  1. Sepsis
  2. Meningitis
  3. Pneumonia
  4. UTI
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15
Q

What are the signs of sepsis in neonates ?

A
  • Seizures
  • Stiff limbs
  • Cyanosis - looks mottled, blueish or pale
  • Cap refill ≥ 3 secs
  • Difficulty feeding
  • Severe chest indrawing
  • Temp ≤ 35.5 or ≥ 37.5
  • Movement only when stimulated
  • RR ≥ 60
  • Lethargy
  • Grunting

Sepsis should always be a differential in neonates

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16
Q

In the early neonatal period (<48hrs) what is the most common causative organisms for sepsis ?

A

E.coli & Group B strep (streptococcus agalactiae)

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17
Q

In late onset sepsis alongside the common ones for early onset what are the other potential causative organisms ?

A
  • Staph. epidermis
  • Listeria monocytogenes
  • Klebsiella
  • Enterococcus
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18
Q

In suspected or confirmed sepsis of a neonate what investigations should be done as an infeciton screen to find the possible source ?

A
  • Blood culture & virology
  • CXR
  • Lumbar puncture
  • Stool sample for virology
  • Urine sample for culture & virology
  • ENT swabs for culture
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19
Q

What is the management of neonatal sepsis ?

A
  • BUFALO (Abx = GAM)
  • then once the cause is found treat as per guidelines
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20
Q

What are the 3 potential causative organsims of neonatal meningitis ?

A

Think GEL

  1. Group B strep
  2. E.coli
  3. Listeria monocytogenes
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21
Q

What are the signs/symptoms of neonatal meningitis ?

A
  • Irritable
  • High pitched abnormal cry
  • Lethargy
  • Difficulty feeding
  • Fever
  • Seizures
  • Bulging fontanelles
  • Apnoea

Note photophobia, stiff neck etc is less common in young kids

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22
Q

How is neonatal meningitis diagnosed ?

A

Lumbar puncture

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23
Q

What is the treatment of meningitis in young kids < 3months and kids > 3months ?

A
  • If < 3 months tx = cefotaxime + amoxicillin
  • If > 3months (upto age of 18) tx = 1st dose cefotazimine followed by once daily ceftriaxone + dexamethasone
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24
Q

What are the signs/symptoms of penumonia in neonates ?

A
  • Malaise
  • Poor feeding
  • Tachypnoea
  • Cyanosis
  • Grunting
  • Respiratory excessory muscle use
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25
How is penumonia diagnosed in neonates ?
CXR + FBC + blood & sputum cultures
26
List the causes of pneumonia neonates, infants & school children ?
* Neonates: GBS, E.coli, Klebsiella, Staph aureus * Infants: Strep pneumoniae, Chlamydia * School age: Strep pneumoniae, Staph aureus, Gr A strep, Bordetella, Mycoplasma, Legionella
27
How is the severity of CAP pneumonia determined ?
Using CURB 65
28
What is the treatment of severe and non-severe CAP in children \< 1 and \> 1y/o ?
Non severe: * \> 1y/o 1st line = amoxicillin, 2nd line = clarithromycin * \< 1y/o 1st line = co-amoxiclav Severe: * 1st line = co-amoxiclav (+ clarithromycin if signs of atypical pneumonia or pertussis)
29
What is the treatment of HAP/post-op/aspiration penumonia in young children ?
1st line = co-amoxiclav
30
What are the signs/symptoms of UTI in neonates ?
* Fever * Vomiting * Lethargy * Irritability * Poor feeding & failure to thrive * May be abdo pain, loin tenderness and other characterisitc symptoms but less likely in younger children
31
When is an upper UTI assumed in young children ?
* Assumed if bacteruria & fever ≥ 38 * OR if fever \< 38 but have loin pain/tenderness & bacteriuria
32
When is lower UTI assumed in young children ?
Assumed in all other children who have bacteruria but no systemic symptoms/signs e.g. fever or loin pain
33
How is UTI diagnosed in young children ?
Clean catch urine for microscopy & culture
34
What is the treatment of lower UTI in children \< 3months and those \> 3months ?
* \< 3months = Amox + Gent * \> 3months = Trimethroprim or nitrofuratoin
35
What is the treatment of upper UTI's in young children ?
* 1st line = Amox + Gent * 2nd line = Co-amoxiclav
36
Define what nectrosing enterocolitis (NEC) is
* This is an inflammatory bowel disorder in which the bowel begins to die (necrosis) * It can then lead to perforation of the bowel which in turn can lead to infection
37
What is the chief risk factor for NEC development ?
Prematurity
38
What are the signs/symptoms of NEC ?
* Poor feeding * Vomiting +/- bile * Swollen & tender abdomen * Blood/mucus in the stool * May present with shock, DIC if severe * Usually presents in the first 2 weeks of life (& primarily in pre-terms)
39
How is NEC diagnosed?
**Abdo X-ray** shows pneumatosis intestinalis (gas within wall of the bowel) - this is pathognomic for it
40
What is the treatment of NEC?
Antibiotics (IV GAM) with step-down to co-amoxiclav +/- surgery
41
What are the 2 types of impetigo ?
1. Bullous 2. Non-bullous
42
What is the causative organism of impetigo ?
Staph.aureus
43
What age group of children does non-bullous impetigo usually affect ?
5-15 yr olds
44
Describe the presentation of non-bullous impetigo
* Starts as tiny pustules or vesicles that evolve rapidly into honey coloured crusted plaques * Plaques usually on the face around the mouth & nose * Satellite lesions may occur as it spreads * May be itchy
45
What age group is more likely to be affected by bullous impetigo ?
Noenates
46
Describe the presentation of bullous impetigo
* Lesions have a thin roof & tend to rupture spontaneously (cause still staph.A think still golden colour) * Usually present on the face, trunk, extremities, buttocks or perineal area * More likely to be painful with associated malaise
47
What is the treatment of impetigo ?
* 1st line = flucloxacillin * 2nd line = clarithromycin If severe 1st line = clindamycin
48
What is oestomyelitis and the main causative organism
* It is infection of the bone marrow which may spread to the cortex & periosteum * Most commonly caused by Staph. A
49
Describe the presentation of osteomyelitis
* Acutely febrile & bacteraemic with markedly painful immobile limb * Swelling & extreme tenderness over affected area * Erythema & warmth over affected area * In neonates sometimes associated with septic arthritis
50
How is osteomyelitis diagnosed?
* Bloods - FBC & inflam markers * Bone culture * MRI
51
What is the treatment of osteomyelitis \>5y/o & \< 5y/o?
* \> 5 = flucloxacillin or clindamycin * \< 5 = Ceftriaxone
52
What is the causative organism of measles ?
RNA paramyxovirus
53
What are the signs/symptoms of measles ?
* Rash on forehead & neck which spreads to the trunk & limbs * Cough * Coryza (inflam of membrane in nose) * Conjunctivitis * Koplik spots = appear on bucal mucosa, small red spots with blueish white centre (pathognomic)
54
How is measles diagnosed?
Saliva swab for measles specific IgM & IgG
55
What is the treatment of measles ?
Symptomatic
56
What are the signs/symptoms of mumps ?
* fever * malaise, muscular pain * parotitis ('earache', 'pain on eating'): unilateral initially then becomes bilateral in 70% (parotid gland swelling)
57
How is mumps diagnosed ?
**Clinically** usually, but can do salivary swab for specific IgM & IgG
58
What is the treatment of mumps ?
Supportive
59
What is the causative organism of rubella ?
RNA virus
60
Descrieb the typical presentation of rubella
* prodrome, e.g. low-grade fever * rash: maculopapular, initially on the face before spreading to the whole body, usually fades by the 3-5 day * lymphadenopathy: suboccipital and postauricular
61
How is rubella diagnosed ?
Serological &/or PCR
62
What is congenital CMV infection ?
This is when infection with CMV passes from mother to baby
63
Does congenital CMV infection typically cause any problems ?
No - but in 10% of babies infection this will cause symptoms
64
Describe the presentation of symptomatic congenital CMV infection
* Jaundice * Pneumonia * Rash - small purplish spots * Enlarged liver & spleen * LBW (small head & body) * Seizures
65
What will the majority of kids with symptomatic congenital CMV infection develop ?
Upto 90% will develop one or more disabilities such as: * Hearing loss * Visual impairment * Blindness * Learning difficulties
66
What is the other name given to erythema infectiosum ?
Slapped cheek disease
67
What is the causative organism of slapped cheek disease ?
Parovirus B19
68
Describe the presentation of slapped cheek disease
1. Initially causes mild symptoms such as - headache, rhinitis, sore throat, low grade fever & malaise +/- N&V 2. After 7-10 days symptoms clear and classic slapped cheek rash appears (erythema on cheeks, sparing the nose, perioral & periorbital regions) 3. The rash may then spread to the extremities but rarley affects the palms or soles
69
If slapped cheek is untreated during pregnancy & passed onto the baby what may it develop ?
Hydros fetalis, hepatis, severe anaemia, inflam of the heart muscle & cardiac muscle
70
When should you think of herpes simplex encephalitis in a child ?
* Think of it in any child with focal or general seizures & CNS signs (esp temporal) +/- decreased conciousness * CNS signs may be mild or gross e.g. hemiparesis
71
What investigations should be done for suspected herpes simplex encephalitis ?
* CSF: lymphocytosis, elevated protein * PCR for HSV * CT: medial temporal and inferior frontal changes (e.g. petechial haemorrhages) - normal in one-third of patients * MRI is better * EEG pattern: lateralised periodic discharges at 2 Hz
72
What is the treatment of HSV encephalitis?
IV aciclovir
73
What is the causative organism of chickenpox & shingles ?
Varicella zoster virus
74
Describe the presentation of chickenpox
* fever initially - systemic upset is usually mild * Itchy, rash starting on head/trunk before spreading. Initially macular then papular then vesicular ==\> ulcers ==\> crusting
75
What is the treatment of chickenpox and what should specifically be avoided ?
* Tx = supportive * Avoid ibuprofen
76
Describe the presentation of shingles
* It is an acute, unilateral painful blistering rash. It affects dermatomes * Occasionally, two or three nerves next to each other are affected. * Very rarely, shingles can affect both sides of the body, but this is usually in people with a weakened immune system.
77
What is the tx of shingles ?
Aciclovir - reduces rates of post-herpetic neuralgia
78
List the symptoms which would make you consider HIV in a child/neonate
* Lymphadenopathy * Hepatosplenomegaly * Persistent diarrhoea * Parotid enlargement * Shingles * Decreased platelets * Recurrent slow to clear infections * Failure to thrive * Clubbing * Unexplained organ disease * CMV, toxoplasmosis infections etc
79
What are the 3 main differentials of a newborn presenting with cyanosis ?
1. Cardiac disease 2. Respiratory disease 3. Persistent pulmonary hypertension of the newborn (PPHN)
80
How do newborns with cardiac disease, resp disease & PPHN typically present differently from eachother ?
* Cardiac babies tend to be blue with little or no respiratory distress. May have pre-post ductal differential * Respiratory causes usually associated with increased work of breathing, xray changes * PPHN often seen in otherwise very unwell babies. Large pre-post ductal differential.
81
What is the initial treatment of a newborn presenting with collapse at the time of duct closure (2-7days postnatally) ?
* ABC – support airway and breathing as necessary * Prostaglandin E2 to open duct * Multisystem supportive treatment * Transfer to cardiac surgical centre for definitive management
82
What are the 4 main congenital heart diseases a neonate may be born with ?
1. Tetralogy of fallot 2. Transposition of the great arteries 3. Coartication of the aorta 4. TAPVD (total anomalous pulmonary venous drainage)
83
Describe what tetralogy of fallot is
This consists of four defects: 1. Pulmonary stenosis 2. VSD 3. Over-riding aorta 4. R-ventricular hypertrophy The VSD allows some deoxygenated blood into the aortas (due to the VSD being beside the opening to the aorta)
84
What are the signs/symptoms of tetraolgy of fallot
* Cyanosis * SOB & tachypnoea esp on exertion * Loss of conciousness * Clubbing of fingers & toes * LBW & failure to thrive * Harsh loud pan systolic murmur +/- thrills
85
Describe what transposition of the great arteries is
This is where the aorta & pulmonary artery are swapped places resulting in deoxygenated blood circulating round the body which is fatal
86
What are the signs/symptoms of transposition of the great arteries ?
* **Cyanosis in the first day of life - often within the first few hours** * Tachypnoea * Laboured breathing * Increased HR * Cold, clamy skin
87
Describe what coartication of the aorta is
This is a congenital condition whereby the aorta is narrowed
88
Describe the presentation of coartication of the aorta
* Usually presents in the first 3weeks of life * Poor feeding & lethargy * Tachypnoea or cardiac failure & shock * BP higher in the upper limbs (R-arm) and lower in the lower limbs * Radio-femoral delay * Weak femoral pulse * Upper body appears pink (well-perfused), lower body appears cyanotic * Mid-systolic murmur in the L infraclavicular area
89
Describe what TAPVD is
* This is a defect where oxygen rich blood does not return from the lungs to the L atrium * Instead O2 rich blood returns to the R side of the heart mixing with deoxygenated blood causing the baby to get less O2 than is needed.
90
Describe the presentation of hypoplastic heart
The newborn may not have trouble for the first few days whilst the ductus arteriosus & foramen ovalae stay patent but once these close they quickly develop symptoms: * Tachypnoea * Pounding heart * Weak pulse * Cyanosis * Non-specific systolic murmur * Cardiogenic shock symptoms * S2 Soft & loud
91
Describe what a tracheo-oesophageal fistula is
This is an abnormal connection (fistula) between the oesophagus & trachea
92
What are the signs/symptoms of a tracheo-oesophageal fistula ?
Usually occur very soon after birth: * Frothy white bubbles in the mouth * Coughing or chocking when feeding * Vomiting * Cyanosis esp when baby is feeding * Difficulty breathing * Very round, full abdomen (probs air)
93
What is a congenital diaphragmatic hernia ?
* This is a defect in the diaphragm allowing herniation of abdominal contents into the chest. * Leading to impaired lung development (pulmonary hypoplasia & pulmonary HTN)
94
What are the signs/symptoms of a diaphragmatic hernia ?
* Difficult resucitation at birth * Resp distress * Bowel sounds in one side of the thorax (usually left) * pH \< 7.3 & cyanosis (due to lung hypoplasia)
95
What is potters syndrome ?
This is a condition with a typical appearance & associated pulmonary hypoplasia of a neonate and is a direct result of oligohydramnios & compression in utero
96
List some of the other congenital conditions covered in other lectures
* Spina bifida * Mytonic dystrophy * Microencepahly = head circumference is smaller than normal and may be assoicated with genetic abnormalities or by drugs, alcohol, viruses & toxins
97
What are the signs of shock in neonates ?
* Increased pulse * Decreaed BP * Decreased urine output * Decreased conciousness
98
What is the management of shock in neonates ?
* ABC +/- ventilation (fluids etc included as norm) * Ionotropes for BP - dopamine 1st * Na bicarbonate if pH \< 7.2
99
Which is more common cardiac arrest or cardiopulmonary arrest in children ?
Cardiopulmonary arrest
100
Describe what hypoplastic heart is
* This is a congenital condition where the L side of the heart does not form correctly e.g. * L ventricle underdeveloped & too small, mitral valves not formed or very small, aortic valve not formed or very small, ascending aorta underdeveloped or too small. * Often have a ASD * Due to the poor function of the L side of the heart the O2 rich blood bypasses that side by going through the patent ductus arteriosus & foramen ovalae (until they close)
101
What is a ventricular septal defect ?
A hole which connects the ventricles
102
What are the causes of VSD's ?
Congenital or aquired (post-MI)
103
What are conditions are congenital VSD's associated with ?
Associated with chromosomal disorders (e.g. Down's syndrome, Edward's syndrome, Patau syndrome)
104
How do VSD's typically present?
May present in infancy with severe heart failure or remain asymptomatic & detected incidentally later in life
105
What are the clinical signs of a VSD?
Classically a pan-systolic murmur which is louder in smaller defects. Heard at the left sternal edge
106
What are the potential complications of a VSD?
* aortic regurgitation * infective endocarditis * Eisenmenger's complex * right heart failure * pulmonary hypertension: pregnancy is contraindicated in women with pulmonary hypertension as it carries a 30-50% risk of mortality
107
What is an atrial septal defect (ASD)?
It is a hole which connects the atria
108
What are the clinical features of an ASD?
* Pulmonary ejection systolic murmur * Fixed splitting of S2 * Embolism may pass from venous system to left side of heart causing a stroke
109
What is the treatment of ASD's and why ?
* Treatment is surigcal closure in children before age 10 * OR Transcatheter closure in adults if symptomatic This is because they carry a significant mortality, with 50% of patients being dead at 50 years.
110
More than 50% of VSD cases spontaneously resolve - T or F?
True
111
What is the management of cardiopulmonary arrest in children & infants ?
* 5 rescue breaths first * then 15:2 for C:V ratio * Rate should be 100-120 BPM and a Depth of 4cm for infants & 5cm for children for compressions * No \> 10secs in assessing signs of life & deciding whether or not to start CPR * Secure airway in a neutral position for infants \< 1year
112
What is hydrops fetalis and its causes?
* This is serious congenital condition defined as abnormal fluid accumulation in ≥ 2 fetal compartments of which may include ascities, pleural effusion, pericardial effusion, skin oedema * Causes include immune (Rh disease & ABO incompatability) and non-immune - cardiac, chromosomal etc

Y4 Neonatology (10 decks)

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