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Can everybody see my screen? Great. OK. So um if you want to join the ment meter presentation, now that might make it more quick to go um to connect during the presentation. So the code for that at ment.com is 3375822533758225. And that's at the top of the screen. And I think it's on the other slides as well. So you can join that in the meantime, and let's begin. So the objectives for today's lecture are we are going to look at understanding an approach to neonatal resuscitation. We're going to define neonatal sepsis. Unless the risk factors for developing neonatal sepsis, we'll appreciate some of the signs that you can observe in neonatal sepsis and how they may be different to typical sepsis in older Children or adults. Um We'll look at the principles of management of neonatal sepsis. We'll also look at neonatal jaundice and how to assess for that. And we'll differentiate between physiological and pathological neonatal jaundice and we'll understand the management approach of neonatal jaundice. OK. So with that, let's start. So you are the neonatal sho on call, you are holding the delivery bleep, the bleep goes off and you are called to a delivery. What information do you want to know from the maternity team? So if you can just put in some free texts about what information you would want to know if you're attending a delivery for a baby and if you're struggling with the mentor to let me know in the chat. Ok, so we've got one answer so far mode of delivery. Good. Is there any fetal distress, expected, birth weight, gestational age, fetal and maternal complications during pregnancy? Ok. History of immediate cry or delayed. So the baby's not quite born yet, but we would want to know that that is important if we got there after the delivery. Ok. Got four responses and 15 people. So any last people want to add any further responses? 54321. Ok. So there were some good answers there. Um So yeah, so basically we need to categorize this into a few different areas. So firstly, we wanna know why do they need us to be at the delivery? So, reasons for attendance or things that are related to the condition of the fetus? So what is the gestational age? So, is it premature, we might want to be there for that delivery um indication for attendance also. Is it meconium? Has it been antepartum hemorrhage? Is there any fetal distress and fetal distress we can see on the CTG for those of you haven't done obstetrics. That's the cardiotocograph, which is a monitor that's on the mother's abdomen and it compares baby's heart rate um in relation to the contractions. And if that's not synced in the right way, that can be a sign of distress. And if the baby's heart rate is too fast, more than 160 or too slow, less than 100 those are also some signs of fetal distress. Um, prematurity is an indication, assisted deliveries, forceps or ventus. Um emergency cesarean sections are another um indication for um attendance which I sorry, I haven't put that on the slide. Um So those are the things that are going on acutely that we need to be there for. We want to know about the mother's health. So does she have diabetes, hypertension, preeclampsia? Um Has she got any infections, syphilis HIV, hepatitis. It's supposed to say written he um HIV twice um torch viruses. So that's stands for toxoplasmosis rubella CMV. And then the H has kind of come to mean herpes hepatitis and HIV. Historically, it was just herpes. Um has the mother used any substances both illicit or medications? Um What is her blood group? And has there been any bleeding during the pregnancy? Ok. We also want to know about the antenatal scans. So, during pregnancy, there are most people who have at least three scans during their pregnancy. It depends where you work, um which barrier you are in and what they offer, um but you'll have your first trimester scan and that will date the pregnancy and it's the most accurate at dating the um pregnancy in the first trimester. And we'll also offer screening for Trisomy 1318 and 21 at that stage. Then you have your 20 week scan, which is called your fetal anomaly scan. And that's when we look at the baby's organs in detail and we see if there's any abnormalities that have formed it by that point or not formed at that point. And then we have a third trimester scan um where we're looking at growth, amniotic fluid if there's too much or too little, again, if there's any congenital abnormalities, um how the baby's lying. So if it's cephalic head down breech or transverse, and then we can also look at umbilical artery Doppler and that shows us what the blood flow is like between the placenta and the baby. And that can affect growth and maturation of the baby. So these are the things that there's probably a lot of other things that obstetricians want to know on the scans. But these are the things as pediatricians that we are most worried about. Ok. And then we also want to know about some risk factors for sepsis. So, is there any maternal infection, prolonged rupture of membranes, which is defined as 24 hours in a term baby, 18 hours in a preterm, baby, um group B strep and spontaneous preterm birth. So any of those things are considered risk factors for sepsis. So, this is what we told about our baby. So the gestational age is 38 weeks. Um There has been rupture of membranes for 27 hours. The mother did receive antibiotics to cover for this. Um The CTG is showing some fetal distress. There have been normal antenatal scans. The maternal blood group is a negative and the maternal virology which is HIV syphilis and hepatitis are negative. Um And so the reason for us to attend now is CTG. OK. So the baby's delivered and they cut the cord immediately and they put the baby in front of you. Um And the baby's color is noted to be blue centrally. The baby's pulse is present but less than 100. The baby is not responsive to stimulation. Um The baby has some tone but it's not fully active and flexed. Um The baby has no signs of spontaneous respiration. So, what is your next action? Um So if we put this in the form of an SBA, you attend a delivery of a 37 week gestational age baby on assessment immediately after birth, the baby has apgars as followers as follows. What is the most appropriate first step to take? Um So option A immediately start CPR option B, dry, stimulate and warm the baby and reassess. Option C provide five inflation breaths and continue down the N LS algorithm. Option D observe the baby for a minute and repeat the apgars and option E cover the baby in a plastic bag and reassess. So if you can answer those questions here, what is the most appropriate first step to take? OK. So we've got eight responses. We'll wait a little bit longer to see if anyone else on the chat is gonna respond. And it seems like most people are saying provide five inflation breasts and continue down the N LS algorithm with a close second of dry stimulate and warm the baby and reassess. Nobody is wanting to start CPR nobody is wanting to just observe and nobody wants to cover the baby in a plastic bag. And we have 1/4 answer on the chat which is b again for drive, stimulate and warm the baby. Another answer on the chat, drive stimulate and warm the baby and reassess that gives us a vibe. All. OK. All right. So the correct answer is dry, stimulate and warm the baby and reassess. So some babies uh so babies when they're born, they need to transition from intrauterine life to extrauterine life. And that means that they need to adjust, opening their lungs, taking an oxygen and clearing the fluid from their lungs and it can take a little bit longer for some babies than for others. Most babies will just require you to dry them, stimulate them, warm the baby and reassess and that will allow them to make their transition um if they don't transition properly, then we would continue down the N LS algorithm. So this is a little bit small. So you may not be able to see it. Um But basically, so as the baby's born, start the clock. And the very first step in that N Ls algorithm is dry wrap, stimulate, keep warm. So it's part of newborn resuscitation. Then if there's still no signs of life, then you'll assess their color tone, breathing heart rate. If the, if there's no signs of life, then you'll open the airway with positioning. And if there's still no signs of life, then you'll go on to give five inflation breaths and then you'll assess again. If there is no response, then you will continue to ventilation breaths, which is 15 shorter breaths. And if they're not responding to that, then you'll move on to compressions. So it takes a lot to get down to compressions. Um And we start with very basic interventions which most babies will respond in the top part of the algorithm. Very few babies go on to needing the later steps in the algorithm. Um Yeah. So that's basically that in terms of the other answers. Um So we wouldn't just observe the baby, we would give them some support. However, having said that when we talk about apgars, um so let's go back to this. So the most important apgars are at one minute of life and five minutes of life. So we don't usually even document their initial apgar at zero minutes. We usually encourage delayed clamping for a full minute. Sometimes a cord is cut earlier if the midwives or obstetricians are worried, um, and they'll bring the baby straight away, but otherwise we give them a minute to kind of adjust by themselves and then we'd reassess at one minute. But if they're not breathing, there's no signs of life. We won't wait for that four minutes. We'll intervene earlier. Um, but then at one minute, we'll want to get the first set of Apgars and five minutes and 10 minutes. That's when we do the repeat acars. Ok. Apgars. Um, just to go over what they stand for. So it's a little bit counterintuitive because it's actually named after a lady called Virginia Apgar who was a midwife who developed the scoring. So they kind of made the letters fit in arbitrarily, but they don't work intuitively. So A for appearance is color. P works for pulse. And you want that to be more than 100 grimace, which is responsiveness, activity standards for tone and respiration is also one that's easy enough. So you kind of just have to learn them because they don't really work intuitively. Ok. So you dried and stimulated the baby, the baby started crying and had beautiful spontaneous respiration. The A guards at one minute of life were eight and the A guards at five minutes of life were 10. So you gave them um the baby to the mother for skin to skin and cuddles. Ok. So now the midwife reminds you that the mother had prolonged rupture of membranes and she asks you if you want to start antibiotics. So according to the nice guidelines on early neonatal sepsis, in which of these cases, would you start antibiotics? Assuming that all of the babies have a normal examination. So, gestational age, 38 weeks, thick meconium seen at delivery, gestational age 36 weeks, maternal diabetes, gestational age 38 weeks, membranes ruptured at 22 hours of life, maternal GBS colonization, gestational age 38 weeks, membranes ruptured 27 hours of life. Maternal, well, not of life of the mother's um labor, maternal GBS colonization, gestational age 36 weeks, membranes ruptured at 15 hours thick meconium at delivery. So I want you to just think about that for now. There isn't an option for answering. Oh, no, there is. I did. Ok. So if you answer that now, that would be great according to nice guidelines on early neonatal sepsis. In which of these cases would you start antibiotics? So just I don't know if you can see it. It's quite small on the mental meter at gestational age, 38 weeks, thick meconium, 36 weeks and diabetes. 38 weeks, ruptured membranes for 2022 hours and maternal GBS, 38 weeks, 27 hours, maternal GBS um 36 weeks, me ruptured 15 hours and thick meconium at delivery. Ok. Um So we've got six for option D and one for option 107 for option D. Are there any final takers? Nothing in the chat on this one? Ok. So the correct answer is D, so that was great. Um So we'll go through the nice guidelines on neonatal sepsis and then we can go through the question again and see if it makes more sense. So, neonatal sepsis is divided into early neonatal sepsis and late neonatal sepsis. Early being less than 72 hours and later being more than 72 hours. Um So, early neonatal sepsis is most commonly caused from pathogens from the birth canal or from chorioamnionitis. So, infection within um intrauterine infection and late sepsis can also be birth canal and chorioamnionitis as well as hospital acquired in babies that are admitted or community acquired. So, the common organisms that are for both of them would be group B strep gram negative organisms, early neonatal sepsis. You also have listeria monocytogenes, um and staph aureus and late, you also have coagulase negative staph and enterococcus. The antibiotic choice in early neonatal sepsis is a bit more narrow spectrum and it's benzylpenicillin and gentamicin. Um So that's a nice guideline. It might slightly differ from center to center. Um Someplace I worked, it's benzopenicillin and Amikacin. So it's always a safe bet when asked about antibiotics to say you would check your local guidelines. Um And late sepsis is usually a cefotaxime, sometimes ketrax and amoxicillin. Um Ketrax has been associated with jaundice, which is why cefotaxime is the prepared antibiotic choice. So, these are based on nice guidelines. Ok. So how do we know if a baby has early neonatal sepsis? So we do something called screening and treating in neonates, which is probably a made up term within the hospitals that we work. But basically any baby who has risk factors for sepsis. So according to the nice guidelines, if they have two risk factors for sepsis, um then you will start them on antibiotics unless you can be rarely clinical. Sure that you don't want to. So as per nice guidelines, two risk factors would mean start on antibiotics or one red flag risk factor. So this is um this document is quite easily accessible on the um nice guidelines. You can just type in nice guidelines, early neonatal sepsis. Um But basically, you can see if before birth for in labor, if you would already at that point, start to identify, are there any risk factors um and continue to monitor those factors throughout labor? If there are risk factors for early neonatal infection or if there are clinical indicators, which we'll get to next um perform an immediate clinical assessment and decide if you want to start antibiotics. Um If group B strep is first identified in the mother within 72 hours of baby's birth, ask those directly involved in the baby's care if they have any concerns in relation to clinical indicators and identify any other risk factors present and look for clinical indicators for infection. So that column on the right, the group B strep is basically you didn't know there was group B strep before the baby was born and then a culture comes back later, um how they you should interpret it. So if there's a red flag and we'll go on to the next page, what the red flags are, but the only red flag currently it's recently been changed is a twin in that same pregnancy has signs of sepsis and you're treating them, then you have to treat the other twin or other triplet. Um or if there's two non red flag risk factors, then you should be doing a screen and treat, which means you perform investigations and start antibiotic treatment. You don't wait for the test results before starting the antibiotics. So straight away, you identify that, that baby's got risk factors at birth. You'll take bloods for a blood culture and a CRP and a full blood count and you'll start the antibiotics if there's no red flags, but there's one non red flag risk factor or one non red flag clinical indicator, then you use your clinical judgment, you assess the baby. Do they seem unwell if they seem ok, you can monitor them and most hospitals will have a policy of monitoring for 12 to 24 hours So if they've just got prom or they've just got GBS colonization, um or they're just premature, then you'll just monitor them more routinely than you would other babies. If there's no red flags or no risk factors, then you're just going to routinely um look after that baby as if there's nothing to worry about. So these are the risk factors. So red flag risk factor is suspected or confirmed infection in another baby in multiple pregnancy. And the non red flag factors are invasive group B strep in a previous baby or maternal group B strep colonization in the current pregnancy. So, if there was a baby who had group B strep meningitis or confirmed group B strep sepsis on a blood culture and was unwell with it in a previous pregnancy, you automatically count that as a um as a risk factor in this pregnancy. Um And if the mother is colonized with group B strep in this pregnancy, that's a risk factor. Bear in mind it's not um NHS policy to test all babies for um all mothers for group B strep. So sometimes the status is unknown, more common than not. Um if the baby is preterm, so less than 37 weeks gestation, if there is confirmed rupture of membranes for 18 hours in a preterm birth or 24 hours in a normal birth, um more term birth and if the mother has sepsis. So if she's got intrapartum fever, higher than 38 or there's any other concerns for suspected sepsis in the mother or a clinical diagnosis of chorioamnionitis. So, otherwise we can diagnose that as if there was maybe fetal tachycardia. The um the amniotic fluid smells really bad and the baby smells really bad. Um So things like that, we can also say is there a clinical suspicion of chorioamnionitis, then if we look at the clinical indicators. So these are signs that you would think about in a baby with neonatal sepsis. So red flag indicators. So I think anybody would act in this situation. So, apneas seizures needing cpr needing mechanical ventilation or signs of shock. So all those babies should automatically get antibiotics, non red flag factors. And some of these you may not consider because they're quite different to older Children or to adults definitely, um which is altered behavior, altered muscle tone. So if they're a bit floppy, if they're not feeding, well, um if they're vomiting or their feeds, um bradycardia or tachycardia respiratory distress, um hypoxia, persistent pulmonary hypertension of the newborn, early neonatal jaundice within 24 hours of birth, um signs of neonatal encephalopathy. Um So those babies would be irritable, have abnormal tone, um temperature abnormalities. So here, this is another one that's quite unique to neonates. So low temperature, less than 36 as well as high temperature, more than 38. Both of those could be related to sepsis, but obviously making sure the room is not too cold or too hot. Um abnormal bleeding, hypo or hyperglycemia and metabolic acidosis. So, these are things that clinically you would consider. Should you be screening this baby for early neonatal sepsis? Ok. So with that, if we go through our question again, according to nice guidelines on early neonatal sepsis, in which of these cases, would you start antibiotics? Assuming that all the babies have a normal examination. So they have no red flag or non red flag risk factors in the clinical indicator column. So, gestational age 38 weeks, their term thick meconium. So meconium is not in itself a risk factor for sepsis. Um It is a reason to monitor the baby, but it's not an indicator for sepsis. Gestational age 30 weeks. So they are premature. So that's one risk factor, maternal diabetes, not a risk factor for sepsis. So that baby would just get enhanced observations. Gestational age, 38 membranes ruptured at 22 hours. Maternal GBS colonization. So they term they don't have prom almost if they went two more hours. Um they have one risk factor which is GBS gestational age 38 membranes rupture 27 hours. So there are prom maternal GBS colonization. So that um is another risk factor. So two risk factors there, prolonged rupture membranes and GBS and then gestational age 30 weeks, 36 weeks. So they premature membranes ruptured at 15 hours. Um They are not prolonged rupture membranes and thick meco at delivery what I will say, but I don't think you should bother yourselves about this for exam because it's more of a theory that people apply in certain hospitals. That there is a, there is some evidence that meconium in premature babies is a sign of listeria. So there are some places which is not according to nice guidelines, but there are some hospitals that will start antibiotics in premature babies with meconium. Um So it's limited evidence, but there is evidence for it. So the person that said e can rest assured that they did have some merit to their answer. Ok. Ok. So we're not gonna do that one again because I think we understand that clearly. Ok. So you've now gone off, you've had your lunch break, you've gone to a few more deliveries, everything's going well, you're towards the end of your shift, you're ready to go home and then the midwife calls you sorry. Um She's concerned about the baby's observations. So these are the baby's observations. They've had a newborn early warning track and trigger chart, which is basically a pus or a news for neonates. Um, so looking at this baby's chart, so we can see that their temperatures were 37 and now they've dropped to 36. Um, they were breathing between 5040 now they've gone up to respirate of 70. Um, their heart rate has gone up to about 165. Their saturations have dropped a little bit between 90 to 94. Um, they got lethargy so they've got a orange flag for lethargy, irritability, poor tone. Um, their feeding is not going so well. It kind of never really has. Um, and the parents are concerned that something's not right with the baby. Um, the baby's sugar is normal so you can see some of the things particularly in that right box are a bit different to the things we'd look for in older Children and adults and they're unique to the newborn early warning chart. Um So I'm going to see if I changed here. So when you go and see the baby, you also can you still see my screen um because it's just not showing a video in that ment screen. Can you still see my screen? Can you see a picture of a baby with a video? Great. Ok. So, and when you look at the baby, this is what you see. Ok. So, OK, so on assessment of your baby, you hear that sound which is grunting that you notice no obvious obstruction to the airway on breathing, you notice subcostal and intercostal recessions with a resp rate of 71 saturations are 88% in air. The capillary refill time which you check by pressing on the sternum is three seconds. Um The heart rate is 100 and 61 with normal heart sounds. There's no murmur, the femoral pulses are palpable and equal bilaterally. The fontanel is soft, it's not bulging. The baby has flexed limbs with primitive reflexes present, the temperature is low. It's 35.9. There's no rash, no jaundice and no other abnormalities noted. Ok. What is the most likely cause of this presentation? So, a term newborn presents with respiratory distress, hypothermia and poor feeding at 12 hours of life. There is a history of prom, what is the most likely diagnosis? Ok. And if you can put your answers, so let me read them to you because they're more. Um this is most likely late neonatal sepsis. Take a blood culture, C RP and initiate cefotaxime within an hour. This is most likely respiratory distress syndrome. Initiate ventilatory support and administer surfactant. This is most likely early neonatal sepsis. Take a blood culture and cop and initiate gentamicin and benzylpenicillin within an hour. This is most likely a ventricular septal defect, arrange for an urgent echo and cardiology consult. This is most likely transient tachypnea of the newborn, continue to monitor the baby on the postnatal ward. OK. So if you can put your answers on the mentee or in the chat, if you don't have access to mentee. OK. So um we've also got in the chat. See. So I think, oh, we've got somebody who's gonna not follow the crowds. We've got one B respiratory distress syndrome and Seven CS. OK. So the correct answer is, in fact, c this is most likely early neonatal sepsis. Take a blood culture and cop and initiate gent and benzyl penicillin. Ok. So if we go through the answers, so sorry, this slide says eight hours, but it doesn't really change it. So it's not late neonatal sepsis because we said late neonatal sepsis occurs after 72 hours of life. So that would be incorrect. Um This is most likely respiratory distress syndrome. So respiratory distress syndrome differentiated from respiratory distress. So respiratory distress syndrome is a syndrome particularly unique to premature infants. And it's the condition otherwise known as hyla membrane disease. And it's for babies who are have insufficient surfactant because they're born prematurely and therefore their alveoli collapse. So in a term, baby, it's unlikely to be respiratory distress syndrome, not saying never say never. But that is the reason that in this kind of stem question, it would not be respiratory distress syndrome. Um This is most likely early neonatal sepsis, take a blood culture and cop and initiate gentamicin and benzyl penicillin. So, common things present commonly sepsis is very common and this would be sepsis until proven. Otherwise, we've got a risk factor which is prem, I mean pro um and we've got a lot of signs of neonatal sepsis. This is most likely a ventricular septal defect arranged for an urgent echo and cardiology consult. So, while it would be correct, to always consider cardiology anomalies in newborn babies who have respiratory distress and to never discount it until you've proven otherwise. Ventricular septal defect is an anomaly that usually presents much later in life. It usually presents with heart failure at about six weeks of life. So, again, although it could present early, it typically doesn't. Um so it wouldn't be the most likely cause of this patient's presentation. Um and then transient tachypnea of the newborn. So that is a diagnosis of exclusion. So basically, some babies will have a bit of take a bit of time to transition again from the intrauterine to the extrauterine life. Um and those babies may have some increased work of breathing in the first hours of life. It usually should be fully subsided by 24 hours, but it is a diagnosis of exclusion. So even in this baby, if it is trying to tachy, you're still gonna do with such significant respiratory distress, hyperthermia, risk factors for sepsis. You'd be really brave not to treat for sepsis to give respiratory support. Because even if this is transient attack me of the newborn, this baby is not well enough to continue to monitor on the postnatal ward, they've got low saturations, they've got significant respiratory distress. So you're anyway going to admit that baby for respiratory support and antibiotics. Ok. So in this situation, I would hope that you would call for help. This is a really unwell distressed baby who's going to need urgent admission, probably going to need CPAP optic flow or um intubation depending on how they respond. Um You're gonna stabilize ABCD as you would with any patient. And again, think of respiratory support and then always think sepsis. So any unwell child baby, always think sepsis, your other differentials would definitely be cardiac. Um Some of the things that would present more earlier would be things like cot although that usually presents at the first few hours of life. Um total. Oh I can't um TG which is transposition of the great arteries that also presents really early. Um So those are things to think about. But you have reviewed the scans which are normal and there's no murmurs and the femorals are present, so less likely but definitely something to think about. And maybe you'll see on an X ray meconium aspiration syndrome. So, babies who were born through thick meconium, they could have um aspirated some of that meconium either just before delivery or just after delivery. And that can cause a meconium pneumonitis. Um congenital pneumonia which is falls under sepsis, but they could have an infection in the lungs itself. Uh respiratory distress in a preterm, TTN metabolic conditions are rare, but something that we need to keep in the back of our minds. Ok. So you'll start your antibiotics. You'll take, you'll first take a blood culture, you'll take a CRP FBC. Um you'll put in a cannula, you'll take um a blood culture and you'll give the antibiotics. And the goal is to do that within an hour of making the assessment that you think this baby is septic. Um And then you can consider a chest X ray and a capillary blood gas, which I would and probably most people would do in this situation. Um So in this baby, so we had an elevated CRP. Any idea what number you would be worried about in CRP, in a baby, you can pop it in the chat. What would we consider an elevated CRP in a newborn baby? Any guesses? No takers? Oh, we've got someone saying more than 10, we've just got her more than 10. Nobody else is going to take an answer. But yes, so generally and according to I think nice guidelines, we do go with the number 10. Um What we do after that depends where you work. But usually if it's higher than 10, we're going to commit the child to a bit longer of antibiotics and if it's significantly higher or the baby's really unwell, we may consider a lumbar puncture um as well, but that is sight dependent, but these are things that we do need to think about. So our a CRP rise rose went up to 28. Um We got the blood culture back after 48 hours and it was negative. There were some chest X ray changes suggestive of the congenital pneumonia. Um but the baby responded really well. They were initially on CPAP but they were weaned to room air by day two of life and they were ready for discharge to the mother on the postnatal ward with a plan to complete five days of antibiotics for congenital pneumonia. So we did really well with that thought the baby was good to go. You went home, you had a day off and then you came back and you were on the postnatal ward shift on the next shift. And the midwife calls you to review the same baby and they now appear jaundiced. So she has performed a transcutaneous bilirubin reading and the result is 300 micromoles per liter. Um The baby is 38 weeks, gestational age. And we remember from the mother's antenatal notes that she is rhesus negative, which of the following are not risk factors for neonatal jaundice, maternal blood group. A negative small for gestational age, prematurity, breastfeeding meconium aspiration. Ok. OK. Any more takers. So we've got exclusive breastfeeding, meconium, aspiration, neck and neck and we've got one take of the maternal blood group. A negative. Um in the chat, we've got exclusive breastfeeding. Um So one more small for gestational age. Oh Another exclusive breastfeeding. Another small for gestational age. Oh, good bit of a change there. So now the small for gestational age, it's taken the lead. I feel like I'm running the horse races here but not so enthusiastically. OK. So the correct answer is, in fact, e meconium aspiration syndrome. So well done to those of you who put that. So um we'll go through why each of those and then we'll come back to it. Ok. Um But for now, just remember the other four are risk factors for neonatal jaundice. Ok. So the midwife call, so we've got the same one. The midwife calls you to review the baby. What is the most correct statement? So this is physiological jaundice. No further actions need to be taken. This baby is at risk of hemolysis due to rhesus incompatibility, take a serum bilirubin blood group and DT and plot the bilirubin results on a treatment threshold graph. This baby is at risk of hemolysis due to reis incompatibility. They will require an urgent exchange transfusion. This is pathological jaundice, start phototherapy immediately and monitor the levels. This baby is at risk of hemolysis due to incompatibility, administer an TD to the baby immediately. OK. So what is the most correct statement? So it's a term baby with a bilirubin of 300. OK. So we've got in the chat, we've got a B um OK. Any last minute takers before we put the answer. OK. So the correct answer is, oh, not, let me do it. OK. So I didn't put a correct answer in the correct answer is B this is baby is at risk of hemolysis due to Rh incompatibility. Take a serum bilirubin blood group and DT and plot the results on a chart. OK. So if we go through jaundice um first and then we'll come back and go through why each of those answers are correct or incorrect. So, neonatal jaundice is really common. Approximately 60% of term babies and 80% of preterm babies will develop jaundice in the first week of life. And about 10% of breastfeed babies will remain jaundiced at one month of life. So, the physiological causes of jaundice is babies have an increased red cell turnover. Um And at the same time, they've got immature hepatic uptake and conjugation. So they are breaking down more red cells. So they've got more hemolysis. And at the same time, they're not able to clear the the breakdown products of the red blood cells. So there are factors that are associated with more significant neonatal hyperbilirubinemia. Um So decreased gestational age or preterm deliveries, low infant birth weights or small for gestational age. Um If you've developed jaundice earlier, then it's more likely to be significant. Um Male sex is I'm not sure the pathology around there. Um visible bruising. Um So if there's trauma from birth that will result in increased hemolysis and that can increase your jaundice or cephalohematoma, which is a swelling um and a collection of blood in the skull so that it's uh can also um make you more likely to get severe jaundice, maternal age, older than 25. I'm not sure the path of is about that. Um maternal diabetes, Asian European or Native American ethnicity, a sibling born with jaundice requiring phototherapy or other treatment, dehydration poor caloric intake, it'll increase neonatal weight loss and breastfeeding. So, breastfeeding is one that I think probably takes people by surprise. So when babies are exclusively breastfed, there is less volume going in. So, in the early days of breastfeeding, you've got Colostri, which is really super rich in nutrients and immunoglobulins and it's excellent for the baby. Um but it does take some time for the volume of milk to come in and it does predispose to jaundice. Having said that we don't promote not breastfeeding because of that, but it is just something to be aware of and to make sure you support those parents through breastfeeding um to make sure those babies are getting enough. Ok. So for me, so I know it's quite tricky between physiological pathological jaundice, early, late, the way that I learned it was always to differentiate between early and prolonged jaundice and that kind of works well in my mind, but you can differentiate it into underlying causes or other ways it works well for you. So, basically early neonatal jaundice can present if it presents in the 1st 24 hours of life, it is always pathological and you treat it as such, which means you're likely to do a septic screen. Um You're going to check the baby's blood group, you're going to check their d which is another name for a Coombs test to see if they've got any antigens against the mother's blood group. Um And you're going to start that baby on phototherapy. If they meet the threshold, we look at the threshold um if it's 24 hours to 14 days of life, that's also considered early neonatal jaundice. And that can be either pathological or physiological. And we'll go through some of the differences there. If it's prolonged more than 14 days or 21 days in a preterm baby, then it's pathological until proven otherwise. And once it's proven otherwise, it could just be physiological. And there is something that's called breast milk jaundice, which babies can stay jaundice for a long period of time. So, um so if we go to some of the causes of pathological jaundice, there are more than this, but these are the most common and basic ones. So, hemolysis, which can lead to a bo incompatibility. So, if the mother's um o positive and the baby's got a group a that, that can cause um a reaction, rhesus incompatibility. So, if the mother is rhesus negative, so just a little reminder that means that she doesn't express any rhesus antigens. So if the baby is rhesus positive, they're expressing an antigen that is foreign to the mother's body and the mother's body won't amount an immune response to the baby. Um Usually that happens on second response. So if the baby's a second baby, if there has been a miscarriage, even if the mother's maybe not aware of a previous miscarriage, and if there's any bleeding during the pregnancy that could also prime the mother's body to, to amount an immune response. Um So mothers who are rhesus negative usually get something called an TD and that prevents, that protects a baby in subsequent pregnancies from amounting um an immune response. Um And then also there's some things like G six P deficiency, which can also cause hemolysis. Um And that is most present in males and of certain ethnicities. So it's one that's a bit difficult to remember because it's a little bit all over the map. But I think it's like Mediterranean, China, India. I think all have high rates of G six PD and some Middle Eastern countries. Um infections. So neonatal sepsis and then hepatitis um as well as some other viruses CMV E BV, obstruction. So, bilary atresia is one of the most common causes of obstruction, endocrine or metabolic conditions. So, hypothyroidism or galactosemia, breastfeeding, jaundice. So that's what we see in early neonatal jaundice because there's a poor volume of intake due to supply of feeding difficulties. So there's nothing wrong with the baby, but they're not getting enough volume um because it isn't feeding diff there are feeding difficulties. Um so that just needs to be sorted and in some case, we would top up with express breast milk or formula. But first prize is to help the mother establish good breastfeeding. Um So if we go back to these questions, um so which of the following are not risk factors for neonatal jaundice. So, all of the top four are meconium aspiration, although it can make the baby look a little bit yellow, um if they covered in meconium, they are not risk factors. So, breastfeeding is in fact a risk factor for developing jaundice. Um and then if we look at this question, um so this baby's term, they've got a bilirubin of 300. Um what is the most correct statement? So the physio, this is physiological jaundice, no further actions need to be taken. So we actually will come to now, you actually need to plot it first. It may, the baby may need phototherapy. Um This baby is at risk of hemolysis due to rhesus incompatibility. So the mom is rhesus negative. So the baby may have a positive blood group. So there may be at risk of hemolysis. Um So we will take a serum bilirubin, a blood group and D. Um and plus the bilirubin results on a treatment threshold graph. This baby is at risk of hemolysis due to incompatibility, they will require an urgent exchange transfusion. So, an exchange transfusion, we'll talk about a bit later, but that would only be in really severe jaundice. So, not all babies with hemolysis will get that. Um This is pathological jaundice, start phototherapy immediately and monitor the levels. Um So that's a bit of a confusing one because it may be, but you actually want to first confirm a transcutaneous bilirubin reading with a serum bilirubin before starting phototherapy. Um And this baby is at risk of him. MS incompatibility, administer anti D. So anti D is given to mothers not to babies. OK. So I hope that is clear. Um So these are the ways that we measure bilirubin in babies. So we have the transcutaneous bilirubin, which is that machine on the top, right? Um And that kind of uses like slight waves to pick up the levels. Um It's nonpainful, it's not invasive, it's not a needle, it's literally a little button that you press down either on the sternum or on the forehead. Um So if the jaundice levels, if the baby is more than 35 weeks or more than 24 hours of life, but less than 14 days of life and they've not had previous phototherapy, you can use the transcutaneous bilirubin and it's a really nice screening tool. Midwives can have it in the community. So babies are jaundice at home, they can use it. It means we don't have to prick babies. So it's really nice if they do fall into those criteria to use it. Um Babies who need a serum bilirubin if the TCB or the transcutaneous bilirubin is more than 250. Um even if that's below the threshold for phototherapy, the machines, um there's data that over 250 they're less accurate. So all those babies need a confirmation with the serum bilirubin or if the baby meets a threshold for phototherapy on a chart, premature baby is less than 35 weeks, 1st, 24 hours of life. Once a baby's been on phototherapy, the, the TCB is no longer effective. Um And obviously, if you don't have a TCB available, then you need to do a serum bilirubin. And that's usually done by a heel prick and take a little biochemistry sample and send to the lab. Ok. And then we got to plot our bilirubins on treatment threshold grafts. It's really important to use the correct graph for gestational age. And we'll look at that now and why that's important and also really important to plot on the exact hour of the baby's life. So you need to find out what time they were born and to plot accurately because every hour makes a difference. So if we look at this, this is a, a chart for a 38 week gestational old baby. Um So we said our baby has a bilirubin of 300. So if we had to plot 300 for a term baby, which our baby is, we can see that it falls just above the phototherapy level. So that was a transcutaneous bilirubin. So therefore, we would need to confirm it with a serum bilirubin and see if the baby needs phototherapy. OK. If the baby's 37 weeks of gestational age, you can see just one little week makes quite a large difference. And you can see that 300 is now quite significantly above the phototherapy line. Um And so it is really important to use the right charts and there's different charts for different weeks of life. If the baby was 36 weeks, you can see how even more significant 300 is getting a bit close to the exchange transfusion line. So, um and then if you look at the bottom of the chart, you've got the days of life, but each one of these columns represents six hours of life. So it's really important to put them in the right column because you can see. So this baby's three days of life. But if you had to put them at exactly day three, they would be um they would be above phototherapy. But if actually there are two days and 18 hours of life and you go a bit earlier, then they relatively much higher over the threshold. So it's really important where you pluck them, especially in the first three days of life. After three days, the charts plateau and it's less important. OK. So phototherapy is basically the use of light waves to bring down bilirubin levels to normal. And it's through a process called photooxidation. So exposure to the green blue light at a specific wavelength produces water soluble isomers of bilirubin. And these water soluble isomers are easier to excrete and break down from the body. So that's phototherapy in very basic principles. Um Putting babies in sunlight does not produce the same effect. So there are different types of phototherapy that we can use. Um So some babies will be in an incubator with overhead lights. Um There is relatively new technology which is called a Billy blanket, which you can see at the top, which is able to go under the baby. And that allows the parents to breastfeed at the same time as a baby receiving phototherapy. Otherwise, you do have to limit breastfeeding to 20 minutes at a time because we want the babies to have maximum exposure to the lights. Um There is some theoretical um evidence of damage to the retina with exposure to phototherapy. In reality, there aren't very many cases of it, but we do protect the eyes because of that and we want maximum skin exposure. So babies should be in nappies, everything else exposed. Um which is why sometimes they are put in an incubator to keep them warm, especially if they're very small babies. Um We then look at hemolytic jaundice. Um So, hemolytic jaundice is most commonly caused from rhesus or a bo incompatibility if it's a severe which is above exchange transfusion on our threshold graphs. Um those babies would need a exchange transfusion and what an exchange transfusion is literally taking blood out of the baby and replacing it with transfusion blood. So, from a normal donor blood, so you would check their blood group and replace it with blood bank blood essentially. Um It's really uncommon that we do exchange transfusions. Usually we'll start with intense photo therapy, give the baby IV fluids, um give them IV immunoglobulins. And if it's still not responding, then we would do an exchange transfusion. And we usually put lines in the umbilical cord and we use the umbilical vein to take out the blood and umbilical artery to put the blood in or vice versa. So it's quite a faff and it's sounds like it's exciting, but it's literally staying there for hours, syringing blood in and syringing blood out. Um So not done. Um really frequently, I've seen one but seen many babies who have levels above exchange. So most of the time we can avoid it. Ok. So we are almost finishing up. I know it is about an hour. So I understand if some of you need to leave. Um But the baby's gone home, you saved them and now you're working in the prolonged jaundice clinic. And the midwife refers the baby for assessment as they are still jaundiced. So this is a term baby at 16 days of life presenting with jaundice. The spr is 300 which of the below statements are true. This is physiological, physiological jaundice continue to monitor with A TCB. This is prolonged jaundice, assess for conjugated hyperbilirubinemia by assessing stool color and measuring conjugated bilirubin. This is prolonged neonatal jaundice admit for phototherapy, this could be breast milk, jaundice, stop breastfeeding and switch to formula. This is prolonged neonatal jaundice, advise the parents to expose the baby to the son. So this is our last question of the day. So let's get everyone's input. OK. So we've got most of our answers for answer. B this is prolonged jaundice assessed for conjugated hyperbilirubinemia by assessing stool color and measuring conjugated bilirubin. Oh, we just got one pop up of this is physiological jaundice continue to monitor with the TCB. Um And we've got two for prolonged jaundice, admitted for phototherapy. Um And we've got one in the chat also for bee. OK. So the correct answer which I did not put on the manter is B this is prolonged neonatal jaundice assessed for conjugated hyperbilirubinemia by assessing stool color and measuring conjugated bilirubin. So once we get to 14 days of life, we cannot call it physiological jaundice unless we've excluded other causes. So, um A would be wrong from that perspective. And we also can't use a TCB after day 14 of life. It's no longer valid. So that's another exclusion criteria for T CBS. So there's two reasons that A wouldn't be correct. B is right. It's prolonged, it's more than 14 days in a term baby. One of the things and the most important thing probably that we want to assess for is conjugated hyperbilirubinemia because we worried about bilia trees. Um So we want to check the, how the stools are if they're pale or pigmented and measure conjugated bilirubin. This is prolonged neonatal, jaundice admitted for phototherapy. So in some cases, we will admit for phototherapy for prolonged jaundice. But most of the time, we aren't so worried about the level of jaundice at that age and there's less risk of developing icterus. Um So it's more that we want to know what the cause is of the jaundice and if the baby is well, we won't necessarily treat it. Um But if we also had to look in a term baby at 38 weeks. So firstly, you can see that the graph ends at 14 days because we no longer really use the graphs after 3014 days. Um and actually 300 would be below phototherapy when you're 14 or 16 days old. So this baby wouldn't need phototherapy. Um They would just need to be work up. Why are they still jaundiced? Um This could be breastmilk jaundice. So that part of the statement is correct, stop breastfeeding and switch to formula. That part of the statement is incorrect and we'll discuss why. Um And the last one, this is prolonged neonatal jaundice, advise the parents to expose a baby to the sun. We do not make that advice. It does not help. OK. So um so prolonged jaundice is more than 14 days in a term baby, 21 days in a preterm baby, we want to examine and assess the baby on history for ensuring that the baby is thriving. So they're feeding well, they're growing, they're gaining weight. There's no signs of infection. We want to make sure there's no obstructive jaundice. So, we worried about bilary atresia, which is, um, the bile ducts not forming properly. Um, and in those cases, those babies will have conjugated, hyperbilirubinemia. So they'll have pale stools and dark urine. It's really important to show the parents what some pictures of what we mean by pale stools. I have parents saying the stools are normal but it's their firstborn and they don't know what the stools are supposed to be. So you've got to show them. So option 12 and three, which are white, chalky stools are abnormal and 45 and six are yellow, green, pigmented stools and that's really great. Brown is also good. So really like get them to point out where their stools fall on a chart. Um And then when we measure the conjugated fraction. So if the conjugated bilirubin is more than 20 or more than 10% of the total bilirubin, if the total is more than 200 those would be abnormal. And in those babies, if there is signs of obstructive jaundice, those babies will get an urgent ultrasound to look for bilary atresia. And it's really important that we screen for bilary atresia because they need to have surgery in the 1st 2 to 3 months of life. And if we miss that window, we're not able to perform that surgery. So that surgery is called a caci procedure and it's a bypass that bypasses the bile duct. Um but it can only be performed in the first few months of life. Um The next step, if we can't do that is a liver transplant and those Children will do less well. So really, really important that we don't miss obstructive jaundice unnecessarily. Um So that's why most midwives will send in at day 14 or 21 in a preterm. And most hospitals will have a prolonged jaundice clinic to screen for that. We also want to consider congenital hypothyroidism and that is checked on your five, your day five spot test your guthrie test. So you can just ask, have they had it done? And do they have a result? And that should be good enough if they have. Um if they haven't had um group ND done, you can consider that at this point. If a full blood count shows ongoing hemolysis, you can also consider G six PD deficiency. Um If everything is negative and normal and the baby is well and the baby is breastfeeding, we can call this breastfeeding jaundice. This may persist for six weeks of life. Um And if we've excluded all underlying pathology, that would be physiological, we don't need to stop breastfeeding. It's not dangerous. We can reassure the parents. So usually when I, when babies home with early jaundice, I'll say if your baby is still jaundiced at 14 days of life, we'll bring them in for another set of tests and an assessment most of the time, there'll still be nothing wrong and you, you can just carry on as normal. But we just need to make sure if there are still jaundice at that stage of life that there's nothing worrying to consider such as bitter atresia. So that is the end of the presentation. So those are the objectives we outlined and I think we have covered all of them. Um If there are any questions I'm happy for you to ask either in the chat or if you feel comfortable speaking, um either about this or anything else that you may have questions on. Um Yeah, and otherwise, uh that's it. I'm gonna stop sharing my screen. Um Oh, sorry, I'm supposed to show you a feedback form which had