WEEK 8 - ADOLESCENCE & CHRONIC DISEASE & NEONATOLOGY Flashcards
7 Key Points?
- What are the 2 key neurobiological changes during adolescence?
- What are the 4 key neuro-behavioural changes during adolescence?
- When do Neuro-typical adolescents gain an understanding of long term health consequences of decisions?
3 Key Symptom Presentations & their Associated Diagnoses?
WA Newborn Bloodspot Screening Program
- When is it performed?
- Screening pathway?
Before a baby can be screened, informed consent must be obtained from the baby’s parent or legal guardian. This involves a midwife or nurse providing information on the test to the family, who can then make a decision about whether the baby will be screened. Once the family has provided their consent, the baby’s heel is pricked and a small sample of blood is collected. This usually occurs 48 to 72 hours after birth. The blood sample is then dried and mailed or couriered to the newborn bloodspot screening laboratory, where it is tested for a number of conditions.
If the screening test is abnormal, follow-up testing must be done to confirm a diagnosis. Most infants with abnormal screening results have normal follow-up testing. In these cases, initial screening results may have appeared abnormal because the blood was taken too early or the baby was premature, among many other factors. Once the diagnosis of a condition is confirmed, treatment starts immediately.
WA Newborn Bloodspot Screening Program
- What are the screening limitations?
- 13 Conditions screened for in the WA newborn bloodspot screening program?
Screening Limitations
Newborn bloodspot screening in Australia is of a very high quality. However, screening tests are not diagnostic. This means they only indicate whether an infant is at increased risk for a condition in the testing panel. In order to confirm whether an infant with an abnormal screening result actually has the condition, additional diagnostic testing is required. While newborn bloodspot screening has proven reliable for the conditions it aims to detect, as with any laboratory test, false positive and false negative results are possible. For this reason, the possibility of a condition should never be ruled out solely based on the screening results and any signs or symptoms of a condition should be followed up immediately.
Chronic lung disease of prematurity
- What is it? Definition?
- Which babies are most severly affected?
- Treatment?
- Terminology & Definitions?
- Chronic lung disease is defined as oxygen dependency at 36 weeks corrected gestational age.
- Those neonates most severely affected by chronic lung disease are babies who are the most premature.
- Diuretics and corticosteroids are effective in achieving short-term improvement in the status of ventilator dependent babies. However, the criteria, dose and duration of steroid use remain controversial.
- There is no consensus on how to wean oxygen in babies with chronic lung disease.
Chronic lung disease of prematurity
- 2 Risk factors for chronic lung disease?
- 3 Broad groups?
- What is the single most important criterion that determines suitability for transfer to a SCN?
Risk factors for chronic lung disease include:
1. Prematurity
2. Peripartum inflammation/infection associated with preterm labour and/or clinical or subclinical chorioamnionitis
postnatal lung injury due to volutrauma, barotrauma,oxygen toxicity, hypocarbia or infection.
Chronic lung disease of prematurity
- Management of chronic lung disease in neonatal intensive care units (NICU) - Respiratory support?
- Drug therapy for established/evolving chronic lung disease? (2)
- Nutrition?
Corticosteroids:
- Dexamethasone is effective in achieving short-term improvement in the status of ventilator dependent babies, as well as longer term reductions in chronic lung disease.
- Typical clinical scenarios where steroids would be considered are a baby who is unable to be weaned from endotracheal MV.
- There is no place for the use of steroids in the treatment of chronic lung disease outside a Level 5 or 6 Neonatal unit.
Diuretics
- Diuretics may be used as an effective short-term therapy for ventilated babies.
- Typical combinations include hydrochlorothiazide +/- spironolactone.
NaCl and KCl supplementation are commonly required.
There is no place for long-term therapy with diuretics in SCNs.
Chronic lung disease of prematurity
- List the 7 Respiratory criteria for transfer to an SCN?
- Oxygen therapy?
Oxygen Therapy
- Oxygen is the one constant in the treatment of chronic lung disease but it has been poorly studied.
- Once weaned from non-invasive respiratory support oxygen is delivered by nasal prongs using low flow (< 0.5 L/min).
- Babies with chronic lung disease have a degree of pulmonary hypertension and are therefore likely to benefit from a more generous oxygen administration regimen rather than from a restrictive policy. Some neonatal units use O2 saturation targets >95% after corrected gestation of 37 weeks. However, the corrected gestational age and the state of vascularistion of the retina need to be taken into consideration.
CAHS Guidelines - Hypoxic Ischaemic Encephalopathy (HIE) and Therapeutic Hypothermia
- What is Hypoxic Ischaemic Encephalopathy?
- Criteria for Therapeutic Hypothermia - 4 Key Points
- 4 Essential Inclusion Criteria?
Criteria for Therapeutic Hypothermia - Key Points
- This guideline is only for newborn infants >35 weeks GA with moderate to severe HIE.
- The positive effects of TH are optimised when started prior to 6 hours of age.
- Avoid hyperthermia (>37.5 C).
- Complete TH Eligibility and Monitoring Chart (MR461.00) if HIE suspected.
- If a neonate meets eligibility criteria 1, 3, and 4 but is 6-12 hours of age, delayed initiation of TH may be considered at the discretion of the attending neonatologists.
CAHS Guidelines - Hypoxic Ischaemic Encephalopathy (HIE) and Therapeutic Hypothermia
- Clinical features of HIE based on the Sarnat Classification?
CAHS Guidelines - Hypoxic Ischaemic Encephalopathy (HIE) and Therapeutic Hypothermia
- 3 Relative contraindications to Therapeutic Hypothermia?
CAHS Guidelines - Hypoxic Ischaemic Encephalopathy (HIE) and Therapeutic Hypothermia
- Key points in Implementing Therapeutic Hypothermia?
- Aim?
- 2 Phases?
- Equipment used?
CAHS Guidelines - Hypoxic Ischaemic Encephalopathy (HIE) and Therapeutic Hypothermia
- Monitoring of Newborn Receiving Therapeutic Hypothermia?
- General? (2)
- Temperature monitoring? (2)
- aEEG Monitoring? (3)
- Investigations - Days 1-5?
General Monitoring
1. Continuous intensive care monitoring (ECG, BP, SaO2, ETCO2).
2. Continuous aEEG monitoring during active and rewarming phase.
Temperature Monitoring
- Rectal probe inserted to depth of 5cm.
- Set temperature alarm limits at 33 (low) to 34 (high).
aEEG Monitoring
- aEEG monitoring should be applied after stabilisation of the newborn.
- It is used for early decision making and monitoring of cerebral activity.
- Up to 50% of infants may develop seizures as a result of HIE.
RCH Guidelines -Screening for children with Down Syndrome
- List some of the medical conditions associated with Down Syndrome?
- Timing of routine visits?
The timing of routine visits should ideally be: during the neonatal period; 3 months; 6 months; 12 months then annually. At each visit, assessment should focus on the associated medical problems listed above as well as parental concerns, family support and education.
RCH Guidelines -Screening for children with Down Syndrome
- Screening guidelines for children with Trisomy 21 - 23 Actions?
RCH Guidelines - Engaging with and assessing the adolescent patient
- What is adolescence?
- 4 Adolescent health care considerations?
- 4 Key Points?
- Confidentiality and consent?
- Adolescence is a transitional phase of growth and development between childhood and adulthood.
- Adolescents have the legal right to confidential health care.
- Adolescents less than 18 years old may be considered ‘mature minors’, capable of giving informed consent.
- The HEEADSSS interview for psychosocial screening is an important component of adolescent assessments.
RCH Guidelines - Engaging with and assessing the adolescent patient
- The Psychosocial interview?
- What is HEEADSSS?
RCH Guidelines - Engaging with and assessing the adolescent patient
- Important things to consider for Examination?
- 5 General considerations of management?
- When can you get your own Medicare card?
- When will an adolescent transition to adult services?
Medicare cards - Anyone over the age of 15 years should be encouraged to obtain their own Medicare card.
Transition to adult services
- Transition to adult services should be considered from mid-adolescence and include formal support and education.
- Most health services will aim to transition an adolescent to adult services by their 18th birthday or once their final year of high school is completed.
- For complex cases, a period of overlap between paediatric and adult services may be required to permit adequate communication between specialists and safe transition.
Phases of Transition in Teenagers with chronic health conditions: moving to adult care
- Transition phase 1: introduction and planning? When? (6 components)
- Transition phase 2: preparation? When? (10 components)
Phases of Transition in Teenagers with chronic health conditions: moving to adult care
- Transition phase 3: transfer? When? (8 components)
- Transition phase 4: evaluation? When? (3 components)
Media use in childhood: Evidence-based recommendations for caregivers
- How much time are kids spending on screens?
- The effect of screen time on the developing brain?
American Academy of Pediatrics (AAP) - Recommendations for media use?
RCH Guidelines Management of Eating Disorders in the ED
- 4 Key points?
- Background?
- Features to ask about on history? Red flag features?
RCH Guidelines Management of Eating Disorders in the ED
- 3 Things to include in Examination?
- 10 Investigations?
- When would you consider admission? (11) 3 Red flags?
Examination
1. Postural heart rate and postural blood pressure
2. Temperature
3. Weight, height and BMI
Investigations
1. 12-lead ECG
2. Blood tests (all patients) - FBE, U&E, Ca, Mg, PO4, LFTs, venous blood gas, glucose
3. Blood tests (new diagnosis) - ESR, thyroid function, coeliac screen
4. Consider nutritional testing (if not done in the last 3 months) including iron studies, B12, red cell folate, vit D and zinc.
RCH Guidelines Management of Eating Disorders in the ED
- Management - Feeding?
- When to perform Cardiac monitoring? (3)
- Which other medical team must be involved?
6 Steps in the management of eating disorders?
What does a comprehensive assessment of a patient with an eating disorder include? (9)
Management of Eating Disorders
- Daily Observations? (7)
- Daily supplementation? (5)
What is Refeeding Syndrome? What are 9 risk factors for refeeding syndrome?
Refeeding Syndrome
Refeeding syndrome is the potentially fatal shift in fluids and electrolytes that can occur following re-introduction of nutrition in patients who are malnourished. This syndrome may not
occur in every starved patient, however due to the potential seriousness and its unpredictability, clinicians should be aware that every malnourished patient may be at risk.
Nutritional Management Algorithm for patients with eating disorders?
Outline a Collaborative Care Plan for managing patients with eating disorders.
- Which health professionals will be involved?
How does the 2014 Mental Health Act (7) apply to the management of patients with eating disorders? (4 aspects)
What information do you need to obtain regarding maternal history for a neonatal history?
- Which pre-existing medical conditions are we most concerned about?
What information do you need to obtain regarding pregnancy complications for a neonatal history?
Complications of pregnancy
- Amniotic fluid: Oligohydramnios /Polyhydramnios
- Bleeding: Placenta previa/ Abruption
- Infectious disease exposure: TORCH, Parvovirus, HepatitisB/C, HIV, Syphilis, Chlamydia
What information do you need to obtain regarding maternal medications for a neonatal history?
- List 7 teratogens.
- List 8 Complications of Substance abuse.
Medications - Teratogens
1. Isotretinoin
2. Anti-epileptic agents (valproate, carbamazepine)
3. Warfarin
4. Chemotherapy agents
5. Radiation therapy
6. Psychiatric agents (lithium)
7. Antibiotics (tetracyclines)
What information do you need to obtain regarding birth history for a neonatal history?
Outline the components of a Cephalocaudal Examination.
- Trunk? (4)
- General? (7)
- 3 Components of growth to check?
- What is a normal RR for a neonate?
- 3 Types of crys and their significance?
Cry
1. High pitched = Neuro stress
2. Hoarse = URT
3. Catcry =Cri-du-chat syndrome, also known as cat’s cry syndrome and 5p- syndrome, is a genetic condition that causes infants to let out a high-pitched cry that sounds similar to that of a cat crying.
Outline the components of a Cephalocaudal Examination.
- 7 Reflexes?
- Movements?
- Skull?
- What is Caput?
- What is Craniotabes?
Caput succedaneum = swelling (edema) that affects a newborn’s scalp. It most commonly occurs from pressure on the head as the baby moves through the birth canal during a prolonged or difficult vaginal delivery. In caput succedaneum, fluid builds underneath the scalp, causing swelling.
Craniotabes = a softening of skull bones that is known to be associated with a variety of pathological conditions, including rickets, hypervitaminosis A, osteogenesis imperfecta, hydrocephalus, or congenital syphilis.
Outline the components of a Cephalocaudal Examination.
- What are you looking for on the head?
- Ears? (4)
- What is the significance of pre-auricular skin tags?
- Eyes?
- Neck? (4)
- Limbs?
- 2 Tests for developmental hip dysplasia?
Pre-auricular skin tags - associated with congenital abnormalities (need to genetic test) & increased risk of hearing loss.
Outline the components of a Cephalocaudal Examination.
- Groin? (4)
- Back? (3)
- Skin - Rashes? (3)
- Skin - Pigmented lesions? (4)
- Skin - Vascular birthmarks? (3)
Outline the sutures of the newborn skull.
- Which 2 suture lines does the anterior fontanelle join?
- Which 2 suture lines does the posterior fontanelle join?
- When do they close?
When will my baby’s fontanelles close?
The posterior fontanelle usually closes by the time your baby is 2 months old. The anterior fontanelle can close any time between 4 and 26 months of age. Around 1 in every 2 babies will have a closed fontanelle by the time they are 14 months old.
List 6 Signs of craniosynostosis.
- What is the outcome of bilateral synostosis of the coronal sutures?
- What is the outcome of synostosis of the sagittal suture?
- What is the outcome of unilateral synostosis of the coronal suture?
Signs of craniosynostosis
1. Abnormal head shape
2. Abnormal head circumference
3. Abnormal eye spacing
4. Ridging suture line
5. Immobile skull plates
6. Narrowed/undetectable fontanelle
What are 4 types of scalp haematomas in a newborn and the space into which blood accumulates?
Which dysmorphic feature is present in this newborn?
= Abnormal palpebral slant
What are the different types of cleft lip and palate?
List Dysmorphic Features of Down Syndrome.
- 10 Face?
- 6 Limbs?
Face
1. Brachycephaly
2. Microcephaly
3. Upward slanting palpebral fissures
4. Epicanthic folds
5. Flattened nasal bridge
6. High arched palate
7. Protruding tongue
8. Dysplastic ears
9. Short, broad neck
10. Ocular anomalies
Limbs
1. Short limbs
2. Short, broad hands
3. Brachydactyly
4. Clinodactyly 5th finger
5. Single transverse palmar crease
6. Gap between hallux and 2nd toes
List 9 Dysmorphic features of FAS?
Fetal alcohol syndrome
1. Microcephaly
2. Small palpebral fissure
3. Epicanthic folds
4. Short nose
5. Flat nasal bridge
6. Flat midface
7. Smooth philtrum
8. Thin upper lip
9. Microagnathia
What are hypospadias? Epidemiology?
3 Types?
Types
- Anterior 50%
- Middle 30%
- Posterior 20%
What are the 2 most common types of palsies associated with brachial plexus injury?
What are Congenital talipes equinovarus?
- Epidemiology?
- 2 Types?
- Cause?
Developmental Dysplasia of the Hips
- Epidemiology?
- Consequence?
- Presentation? (5)
- 8 Risk factors?
Developmental Dysplasia of the Hips
- 1% of neonates
- Disruption in relationship between acetabulum and femoral head
- Leads to hip subluxation and dislocation
- Presentation:
1. Ortolani
2. Barlow
3. Galeazzi sign
4. Loss of full abduction
5. Clicks not a sign of DDH
What is the Barlow Test?
What is the Ortolani Test?
Barlow
- Determines if hip is dislocatable.
- Femur is flexed and adducted while posteriorly-directed pressure applied.
- Displaces an unstable hip from the acetabulum.
Ortolani
- Reduces a posteriorly dislocated hip.
- Femur is flexed and abducted with anteriorly-directed pressure.
- “Clunk” of relocation as femoral head enlocated.
What is this?
What is this?
Stork marks
What is this?
Skin: mongolian blue spot
What are these? Significance?
What is this? Significance?
strawberry haemangioma
Jaundice of the Newborn
- Epidemiology?
- What is jaundice?
- Complications?
- Pathogenesis?
Epidemiology
- Hyperbilirubinemia is a common and usually benign problem in neonates.
- Jaundice is observed in first week of life in 60% of term and 80% of preterm infants.
- Kernicterus is extremely rare, but has high morbidity and mortality
Jaundice
- Jaundice refers to yellow discolouration of skin, from accumulation in skin of bilirubin pigment
- Untreated unconjugated hyperbilirubinemia is potentially neurotoxic
- Conjugated hyperbilirubinemia often signifies serious illness, but is not neurotoxic
Jaundice of the Newborn
- Classification: type of bilirubin?
- Causes of Unconjugated?
- Causes of Conjugated?
Unconjugated - can be Physiological or Pathological
Conjugated = Always Pathological
Jaundice of the Newborn
- Classification: age of onset?
- List 6 Causes of Jaundice of the Newborn with onset < 24 hrs after birth?
Classification: age of onset
- < 24 hrs = Always pathologic
- Day 2 to 3 = Usually physiological
- Day 3 to 1 week
> 1 week
- Persistent
What is the aetiology of ABO Incompatibility in Jaundice of the Newborn <24hrs old?
- 3 Clinical indicators?
What is the aetiology of Rhesus disease in Jaundice of the Newborn <24hrs old?
- 5 Clinical indicators?
What is the aetiology of G6PD deficiency in Jaundice of the Newborn <24hrs old?
- 4 Clinical indicators?
- 3 Causes of Jaundice of the Newborn with onset on Day 3 to 1 week?
- 9 Causes of Jaundice of the Newborn with onset on > 1 week?
- 6 Causes of Persistent Unconjugated Jaundice in a newborn?
- 4 Causes of Persistent Conjugated Jaundice in a newborn?
Day 3 to 1 week
1. Sepsis
2. UTI
3. Infection (CMV, enteroviruses etc)
> 1 week
1. Congenital hemolytic anemia (spherocytosis)
2. Enzyme deficiencies
3. Breast-milk jaundice
4. Sepsis
5. Biliary atresia
6. Neonatal hepatitis
7. Galactosemia
8. Hypothyroidism
9. Cystic fibrosis
**What is Breast-milk jaundice? **
- Epidemiology?
- How does the pattern differ to physiologic?
- Cause?
What is Biliary Atresia?
- 5 features on Liver biopsy?
- Treatment? (3)
What investigations will you perform for a jaundiced neonate?
- 1 Standard?
- 4 Hemolysis?
- 3 Other?
- 3 from Guthrie test?
- 6 Conjugated?
Standard
1. Serum bilirubin - Total & Conjugated and unconjugated
Hemolysis
1. Full blood picture and smear
2. Reticulocyte count
3. Blood group
4. Coomb’s test
Other
1. Enzyme studies
2. Urine
3. TFTs
What is the Clinical Presentation of Jaundice in a Newborn?
- What is the Kramer Score?
Clinical presentation
- Jaundice appears at variable stage, depending on cause
- Begins on face, spreads to abdomen and then to legs as level increases
- Clinical appearance helpful but not reliable to predict serum levels
- Unconjugated usually yellow/orange and conjugated usually muddy yellow/green
- Other signs: Lethargy & Feed poorly
The Kramer score defines the intensity of jaundice based on the dermal advancement from head to hands and feet.
1 = head and neck
2 = trunk to the umbilicus
3= groin including upper thighs
4 = knees and elbows to ankle and wrists.
5 = feet and hands including palm and soles.
What is Kernicterus?
- 10 Signs?
- Complete syndrome?
- Mortality?
Kernicterus = Neurological syndrome resulting from deposition of unconjugated bilirubin in brain cells which develops at high levels of unconjugated serum bilirubin.
Signs
1. Lethargy
2. Poor feeding
3. Loss of Moro
4. Decreased tendon reflexes
5. Respiratory distress
6. Opisthotonus
7. Bulging fontanelle
8. Twitching
9. High-pitched cry
10. Seizures
What is the Moro reflex? Clinical signifance?
The Moro reflex is an infantile reflex that develops between 28 and 32 weeks of gestation and disappears at 3–6 months of age. It is a response to a sudden loss of support and involves three distinct components:
1. spreading out the arms (abduction)
2. pulling the arms in (adduction)
3. crying (usually)
It is distinct from the startle reflex. Unlike the startle reflex, the Moro reflex does not decrease with repeated stimulation. The primary significance of the Moro reflex is in evaluating integration of the central nervous system.
What are the 2 ways of classifying neonatal infection?
Classification: Age of onset
Early (birth to 1 week)
- Usually < 72 hours
* Maternally acquired
Late (8 to 28 days)
- Nosocomial or community acquired
- Sometimes maternally acquired with late presentation
What is the pathogenesis of Prenatal Infections?
- Which organisms? (STORCH)
- 8 Outcomes of Perinatal Infections?
Pathogenesis of Prenatal Infections: Organisms = TORCH (STORCH)
* Syphilis
* Toxoplasmosis
* Other – VZV, Hepatitis B, HIV, Parvovirus B19, Listeria
* Rubella
* CMV
* HSV
5 Risk Factors for Prenatal Infections?
8 Clinical presentations of Prenatal Infections?
Risk Factors for Prenatal Infections
1. History of illness in mother or siblings during pregnancy
2. Primary infection herpes simplex virus in mother
3. History of previous maternal herpes simplex virus
4. Exposure to cats, sandpits
5. Food history
What is the Pathogenesis of Perinatal Infections?
- Which organisms?
- 8 Risk factors?
- Management principles/ prophylactic treatment? Risk of sepsis?
Pathogenesis of Perinatal Infections
- Acquired just before or during delivery.
Organisms
- Any organism from vagina or lower GIT
- Bacterial: Group B Streptococcus, Enteric, Chlamydia
- Viral: HSV & Enterovirus
Risk factors for Perinatal Infection
1. Premature labour
2. ROM > 18 hours
3. Maternal GBS positive status
4. Maternal chorioamnionitis: Fever > 38°C, Maternal leucocytosis, Uterine tenderness
5. Fetal distress/tachycardia
6. Difficult/traumatic delivery
7. Resuscitation at birth
8. Meconium aspiration
Pathogenesis of Postnatal Infection
- Transmission?
- 9 Nosocomial Risk factors for Postnatal Infection?
- Which Organisms: Nosocomial? Community?
Nosocomial risk factors for Postnatal Infection
1. LBW
2. Premature
3. Length of stay
4. Invasive procedures
5. Interventions (catheters, shunts, IVC, EFF)
6. Use of antibiotics
7. Blood transfusion
8. Colonization
9. Transmission via staff and visitors
What are the common types of Neonatal infection?
- 4 Organisms causing Congenital pneumonia?
- 5 Organisms causing Perinatal pneumonia?
- 4 Organisms causing Postnatal pneumonia?
Types of infection
- Focal
1. Conjunctivitis
2. Cellulitis
3. Mastitis
4. Omphalitis
5. Pneumonia
6. Meningitis
-
Systemic
1. Bacteremia
2. Sepsis
Neonatal meningitis
- Transmission?
- 7 Common Organisms?
Neonatal Sepsis
- Systemic Illness presentations?
- Which organisms?
Neonatal Sepsis - Organisms
Bacterial
1. GBS
2. E coli
3. Listeria
4. Coagulase-negative staphylococci (CoNS)
Viral
1. HSV
2. Enterovirus
3. Adenovirus
Fungal - Candida
Describe the Clinical Presentation of Neonatal infection?
- Respiratory?
- CVS?
- Renal?
- CNS?
Which Investigations will you order for suspected Neonatal Sepsis?
Diagnosis: Neonatal Sepsis
Standard septic screen
1. FBP (↑WCC, ↑↓neutrophils)
2. CRP
3. Blood cultures
Other investigations if indicated
4. Lumbar puncture
5. Urine (SPA or catheter)
6. Gastric aspirate/ear swab
7. CXR
8. Viral studies
Describe the principles of managing a sick baby?
- Supportive care: Respiratory support? CVS support? Fluid and electrolyte support? Coagulation support? Hyperbilirubinemia?
Management principles: Sick baby
1) Neonatal nursery
2) Monitor: RR, HR, oxygen saturations, BP & Blood glucose level
3) Septic screen and ANTIBIOTICS
- Immediately if sick
- After 4 hours if respiratory distress only
- EVEN IF NO RISK FACTORS FOR INFECTION
4) Get advice
Antimicrobial Treatment for Neonatal Sepsis
- Which generic broad spectrum?
- Which Ab for meningitis?
- Which Ab for S aureus?
- Which Ab for CONS?
- Which Ab for GNB?
- Which Ab for anaerobes?
- Which tx for HSV?
- Duration of treatment?
Antimicrobial Treatment for Neonatal Sepsis
- Generic broad spectrum antibiotics: Penicillin and gentamicin
Others for specific organisms/infections
- Cephalosporins for meningitis
- Flucloxacillin for S aureus
- Vancomycin for CONS
- Meropenem for GNB
- Metronidazole for anaerobes
- Acyclovir for HSV
- Antifungals for candida
What are the different ways to define prematurity? Which is better?
Definitions: gestation vs size
- Premature: Liveborn infants delivered before 37 weeks
- Low birth weight (LBW): Weight 1000-2500 gm
- Very low birth weight (VLBW): Weight < 1000 gm
- Small for gestational age (SGA)/ Intrauterine growth retardation (IUGR): Weight < 2500 gm inappropriate for gestational age
List the Identifiable causes of Prematurity.
- 2 Fetal?
- 3 Placental?
- 2 Uterine?
- 4 Maternal?
- 3 Other?
What are 3 methods for assessing gestational age?
Assessment of gestational age
- Last normal menstrual period (LNMP)
- Antenatal ultrasound evaluation
- Ballard scoring system: Accurate to ± 2 weeks, Physical and neuromuscular criteria, & High score older gestation
List the Complications of Prematurity.
- 6 Respiratory?
- 5 Cardiovascular?
- 6 Gastrointestinal?
- 4 Metabolic/Endocrine?
- 10 CNS?
- 6 Haematologic?
- 4 Renal?
Apnoea of Prematurity
- Definition?
- 8 Causes?
- Rates?
- Management?
Apnoea of prematurity
- Absence of breathing in the premature infant for a period of > 15 seconds, associated with bradycardia and/or hypoxia
Causes
1. Systemic illness: sepsis, hypovolemia, shock
2. Airway obstruction
3. CVS: PDA, CCF
4. CNS: IVH, seizures, asphyxia, malformations
5. Drugs: opiates, sedatives
6. Metabolic: hypocalcemia, hypoglycemia
7. Hypothermia, hyperthermia
8. Gastroesophageal reflux
Patent ductus arteriosus (PDA)
- 5 Effects?
- 2 Treatments?
Patent ductus arteriosus (PDA)
Effects
1. ↑ pulmonary blood flow
2. Worsens respiratory problems
3. Volume overload
4. Cardiac failure
5. Poor growth
Treatment
1. Indomethacin
2. Surgery
What is Necrotising Enterocolitis?
- Causes?
- Epidemiology?
- 5 Risk factors?
- Clinical picture?
- 6 Systemic signs?
- 3 Radiological features?
- The causes of necrotizing enterocolitis are not fully understood but multiple factors contribute to the development of the condition: Defective or underdeveloped immune system & Formula feeding
- 5-10% of < 32 weeks
- Up to 50% mortality if surgery required
- NEC is the most common cause of acute abdomen in premature infants.
Risks
1. ↓ gestational age
2. Asphyxia
3. Post cardiac surgery
4. Post exchange transfusion
5. Rapid enteral feeding
What does this neonate have?
= Necrotising enterocolitis
Radiological features
1. Intramural gas (pneumatosis intestinalis)
2. Free intraperitoneal air (bowel perforation)
3. Portal venous gas
Pneumatosis intestinalis: bubbles of gas within the wall of the intestine
4 Differential diagnoses of necrotizing enterocolitis?
What is Intraventricular haemorrhage of the Newborn?
- 9 Risks?
- Incidence?
- Clinical picture?
= Bleeding in the subependymal germinal matrix
Risks
1. ↓ gestation
2. RDS
3. Hypoxic insult
4. Hypotensive insult
5. Reperfusion injury
6. ↓↑ cerebral blood flow
7. Pneumothorax
8. Hypervolemia
9. Hypertension
Intraventricular haemorrhage of the Newborn?
- 4 Grades?
What is Periventricular leukomalacia?
Retinopathy of prematurity
- 4 Risks?
- Clinically? (4)
- Pathophysiology?
- Findings? (4)
Risks
1. ↓ gestation (< 32 wks)
2. ↓ birthweight (< 1500 gm)
3. Supplemental oxygen
4. Genetic
Clinical
1. Blindness
2. Retinal detachment
3. Myopia
4. Strabismus
List the Sequelae of low birthweight.
- Respiratory failure? (7)
- Hypoxia/ischemia? (5)
- Intraventricular haemorrhage? (4)
- Gastrointestinal? (7)
- Sensorineural injury? (11)
- Social stress? (3)
- Other? (4)
How would you address concerns raised by a parent regarding their 14y child who seems “addicted” to internet gaming or social media as a primary health practitioner (e.g. GP)?
Analysis: This is a question requiring reference to evidence-based standards, and how to apply them in a socially and psychologically unique circumstance. This is not easy. The evidence-based standards are not well formed owing to the relative recency, dynamic and progressive nature of social media use. Application to the clinical circumstance also requires knowledge of the expectations of the family and parents, beyond understanding the eco-bio-psycho-social health of the patient.
A 15 year old presents with an episode of collapse. What how would you clinically reason regarding this and what important differentials should be considered in the diagnostic reasoning?
Analysis: What does “collapse” mean anyway!? But it is used in layperson language to describe sudden (usually transient) loss of posture and consciousness. Syncope is probably a better medical term, but even this begins to imply a particular group of conditions (vasovagal/neurogenic, orthostatic, cardiac), whereas “collapse” might include seizures, strokes, intoxication, hypoglycaemia…..what a list of possibilities!
“How would you clinically reason” just means: how are you going to use the data from history, examination and investigations to determine the likely diagnosis, and how to determine appropriate management for this particular patient – so it actually covers quite a lot.
A 15y old girl with Down Syndrome presents with increasing lethargy and irritability. Describe an approach to diagnostic reasoning.
Analysis: We need to consider the risks associated with both being an adolescent, but also with having Down Syndrome. Lethargy and irritability are vague symptoms attributable to a range of biological and psychological conditions, so a broad differential needs to be imagined. “Diagnostic reasoning” means consideration of history, physical examination and investigations (and perhaps, consultation) which may help to refine the diagnosis.
Neuro-cognitive maturation continues during adolescence and into early adulthood. What are the important neurocognitive changes (this might be complex and multidimensional) which occur during adolescence, and how are these changes significant in clinical practice?
There are two cellular level processes happening during adolescent neurodevelopment:
1. Myelination – which improves the speed and efficiency of neurotransmission. This is what makes adolescence a period of immense learning potential.
2. Arborisation (a.k.a. “pruning”) – which also contributes to the efficiency of networks by removing unused or less useful networks. Disruption of pruning may be an aetiopathogenic factor in psychotic illness, and may be affected by substance use.
There are also neuronal network level processes happening during adolescent neurodevelopment: Limbic maturation occurs in advance of cortical development, which means adolescents experience:
- More profound reward perception (and willingness to take risks for those rewards)
- More profound lability and depth (or “bandwidth”) (both positive and negative) of mood / emotional state (hence the “moodiness” sometimes observed in adolescence)
- Without necessarily having the words or abstract self-reflective ability to explain their experience (hence the sometimes mono-syllabic responses when adolescents are asked “how are you?”)
