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Neonatology Anya Soin 5 year medical studentLearning Objectives This session will cover the following: • Problems of prematurity • Birth Injuries • Neonatal jaundice • Neonatal respiratory distress • Gastrointestinal disorders • Neonatal sepsisProblems of prematurity Retinopathy of prematurity • Abnormal development of the blood vessels in the retina • Can result in retinal detachment, scarring and blindness Risk factors -> High concentration oxygen therapy, preterm birth Screening -> Babies born before 32 weeks/ under 1.5kg should be screened for ROP biweekly • Starts at 30-31 weeks gestational age if born before 27 weeks • Starts 4-5 weeks of age if born after 27 weeks Management -> Transpupillary laser photocoagulation if there is neovascularisationProblems of prematurity Necrotising Enterocolitis (NEC) Investigations: • Bacterial infection of ischaemic bowel wall • Abdominal x-ray is gold standard – supine position • Life threatening emergency Findings -> dilated bowel loops, bowel wall oedema, pneumatosis intestinalis, pneumoperitoneum Risk factors -> Low birth weight/ prematurity, formula feeds, respiratory distress, sepsis, congenital heart disease Management: • Nil by mouth -> IV fluids,TPN and antibiotics Presentation: • NG tube to drain fluid and gas • Intolerance to feeds • Immediate referral to neonatal surgeons • Vomiting -> look out for green bile • Generally unwell Complications - Perforation/ peritonitis - Short bowel syndrome • Distended and tender abdomen - Sepsis - Abscess formation - Strictures • Absent bowel sounds - Death - Recurrence - Stoma • Blood in stoolsProblems of prematurity Intraventricular haemorrhage -> blood leaking into the ventricles Risk factors: • Prematurity (highest risk in babies born more than 10 weeks early) • Respiratory distress syndrome • Unstable BP • Other medical conditions at birth Screening: • All babies born before 30 weeks require an ultrasound on day 1-2 of life • Babies born 30-34 weeks may also have screening if they have symptoms* Management -> no way to stop the bleeding, but symptoms can be managed Prognosis -> depends on severity of bleeding (Grades 1-4)Birth Injuries Caput succedaneum -> bleeding above the periosteum • Pressure against the cervix during birth • Within skin -> swelling crosses the suture lines • Resolves in a few days Cephalohematoma -> bleeding below the periosteum • Due to damage to blood vessels during delivery • Confined to margins of skull sutures • Resolves in a few weeks Chignon -> Oedema and bruising due to Ventouse delivery Neonatal jaundice Causes -> can be split into increased bilirubin production and decreased clearance of bilirubin Increased production Decreased clearance Haemolytic disease of the newborn Prematurity Rh/ABO incompatibility Breast milk jaundice Sepsis Neonatal cholestasis G6PD deficiency Biliary atresia Polycythaemia Gilbert syndrome Intraventricular haemorrhage Endocrine disorders Jaundice in the first 24 hours of life is pathological and needs urgent investigation Babies with jaundice in the first 24 hours of birth need treatment for sepsis if any risk factors or clinical features are present!Neonatal jaundice Prolonged jaundice -> further investigations required to look for underlying cause • More than 14 days in full term babies • More than 21 days in premature babies Investigations: • FBC/ blood film -> polycythaemia or anaemia • Conjugated bilirubin -> elevated levels indicate a hepatobiliary cause • Blood type testing -> both mother and baby for ABO/ rhesus incompatibility • Direct Coombs Test -> haemolysis • Blood and urine cultures -> sepsis? • G6PD levels -> rule out deficiencyNeonatal jaundice Management: • Total bilirubin levels monitored and plotted on treatment threshold charts • Usually treated with phototherapy* Phototherapy -> converts unconjugated bilirubin into water-soluble pigments that can be excreted without requiring conjugation in the liver • Blue-green light is best for breaking down bilirubin • Once complete, a rebound bilirubin should be measured 12-18 hours after stopping therapy to ensure the levels have not risen above the treatment threshold again Exchange verification -> if bilirubin levels are dangerous • Replace twice the infant’s blood volume with donor bloodNeonatal Respiratory Distress (NRD) Respiratory Distress Syndrome (RDS) -> surfactant deficiency Symptoms: tachypnoea, nasal flaring, expiratory grunting, cyanosis (if severe) Risk factors: preterm (<32 weeks), maternal diabetes Prevention: antenatal steroid 48 hours before delivery if <34 weeks Investigations: hazy “ground glass” appearance on x-ray Management: artificial surfactant (CPAP or supplementary oxygen may be needed) Transient Tachypnoea of the Newborn (TTN) -> delayed reabsorption of lung fluid Most common cause of NRD Risk factors: c-section, preterm, maternal analgesics, maternal asthma Management: ambient oxygen, should resolve in 24 hoursGastrointestinal disorders Oesophageal atresia -> associated with other congenital malformations Risk factors: polyhydramnios Symptoms: persistent salivation, aspiration/choking on feeding Management: surgery Exomphalos/ Omphalocele -> protrusions of bowel through umbilicus • Covered with transparent sac • Manage with IV antibiotics and surgical repair Gastroschisis -> protrusions of bowel through abdominal wall Risk factors: maternal drugs, smoking, illness and younger maternal age • No covering of bowel contents • Manage with IV antibiotics and surgical repair within 4 hours Exomphalos GastroschisisNeonatal sepsis Emergency -> significant morbidity and mortality for the affected infant Common organisms Risk factors • Group B Streptococcus* - Vaginal GBS colonisation • Escherichia coli (E. coli) - Maternal sepsis or fever >38 • Listeria - Prematurity (<37 weeks) • Klebsiella - Early rupture of membrane • Staphylococcus - Prolonged rupture of membranes Features - Fever - Respiratory distress - Tachycardia/ bradycardia - Reduced tone - Vomiting - Jaundice within 24 hours - Poor feeding - Hypoxia - Seizures - HypoglycaemiaNeonatal sepsis Red flags • Confirmed or suspected sepsis in the mother • Signs of shock • Seizures • Term baby needing mechanical ventilation • Respiratory distress starting more than 4 hours after birth • Presumed sepsis in another baby in a multiple pregnancy Management • Start antibiotics if there are 2 or more risk factors/ clinical features or one red flag -> start within an hour of decision after taking blood cultures • Monitor observations and clinical condition for at least 12 hours if there is 1 risk factor/ clinical features • Perform a lumbar puncture if infection is strongly suspected or features of meningitis are presentNeonatal sepsis Antibiotic choice -> check local guidelines NICE guideline recommends benzylpenicillin and gentamicin Ongoing management • Check CRP at 24 hours • Check blood culture results at 36 hours • Consider stopping antibiotics if the baby is clinically well with both CRP results less than 10 and blood cultures negative after 36 hours • Check CRP on 5 days if still on treatment -> consider stopping antibiotics if baby is clinically well, lumbar puncture and blood cultures are negative, and the CRP has returned to normal • If lumbar puncture has not already been done, consider if any CRP results are more than 10Now for some questions! A baby is born at 32 weeks gestation and transferred to the neonatal unit. Over the next few hours, the baby exhibits nasal flaring, chest wall indrawing, and appears to be jaundiced. Observations are a heart rate of 72/min, a respiratory rate of 70/min, and a temperature of 38.1ºC. Which organism is most commonly responsible for the likely diagnosis? A: Listeria monocytogenes B: Staphylococcus aureus C: Staphylococcus epidermis D: Group A streptococcus E: Group B streptococcus Answer - E Reasoning -> Group B streptococcus is the most common cause for early onset neonatal sepsis in the UKNow for some questions! A newborn female baby is noted to have a clicky left hip during the routine newborn examination. What is the most appropriate investigation? A: X-ray B: Urine dipstick C: Ultrasound D: Serum bone profile E: MRI Answer - C Reasoning -> NICE guidelines state that ultrasound is the investigation of choice for DDHNow for some questions! A male infant is born prematurely at 34 weeks gestation by emergency caesarean section. He initially appears to be stable. However, over the ensuing 24 hours he develops worsening neurological function. Which of the following processes is most likely to have occurred? A: Extradural haemorrhage B: Subdural haemorrhage C: Subarachnoid haemorrhage D: Intraventricular haemorrhage E: Arteriovenous malformation Answer - D Reasoning -> IVH is the most likely cause of worsening neurological function in a premature infant of this gestationNow for some questions! A 25-days-old newborn presents to the emergency department with his parents. He has a distended abdomen and looks lethargic.The parents report that he has been feeding less during the last three days and vomited repeatedly.They describe the vomit as bilious.This morning he produced stools with blood in them, but he has no fever. He was born at 35 weeks following premature rupture of membranes. Now he is otherwise healthy. Given the most likely diagnosis, which one of the following investigations should be performed? A: Abdominal ultrasound B: Abdominal x-ray C: Laparotomy D: Test feed E: Upper GI tract contrast study Answer - B Reasoning -> The gold standard diagnostic investigation for NEC is an abdominal x-ray Thank you for listening! Feel free to email me with any questions: mzyas32@nottingham.ac.uk