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Hello. Um Can people hear me? Ok. Amazing. Thank you. Um So I'm Chloe, I'm one of the fourth year medical students. Um and I closure of the Pediatric Society. Um So today is the second part of our teaching series, which is neonatology. Um And we've split this into two parts cos it's quite a big topic. Um So today is part one and then part two will be tomorrow. Um Part one, today's probably gonna be a little bit shorter than it is tomorrow. It's probably gonna be about 45 minutes. Um I'll just see how many people we we've got and then we'll get started in a second if anyone's got any questions as we go along, um, just type in the chat. Um And then I'll be able to check them at the end. Um, but I'll try to keep an eye out throughout as well. Um And if anyone's got any questions about neonatal care or anything to do with your SSC, I do my SSE in at the R VI in the neonatal unit so I can get you in touch with people if that's something that you'd be interested in. Ok. So I'll get started. So the topics that we'll be covering today um are prematurity small for gestational age, respiratory distress stress syndrome, transient tachypnea of the newborn meconium, aspiration and hypoxic ischemic encephalopathy. Um And then tomorrow we'll be covering sort of the rest of the neonatal core conditions. Um So how it's gonna work is I'm gonna go through a couple of cases. Um and we'll see. So we've got, I've got some questions that can come up throughout. So our first case is a 36 year old female presents a maternity unit at 31 plus two weeks, gestation with regular painful contractions and preterm rupture of membranes. So, she's diagnosed as being in preterm labor. Uh And then we have, I've got my first question. So in regards to prematurity, I'll just see if I can set up the um um sorry, I'm not very good at using metal. So you should be able to see a poll on your screen now. And if I would like, if you can define what very preterm is, I'll give a couple of minutes for people to do that. I'm also aware that most of you won't have done sort of most of your pediatric teaching yet. Um So just have a guess at the questions. I'll just give another few seconds. Ok. So we've got 12 responses there. So there are a couple of different definitions um in terms of pre uh in terms of prematurity. So, preterm is defined as before 37 weeks. So anything after 37 weeks will be classed as a term pregnancy. Um, so obviously, sometimes you'll hear parents say that Children were born two weeks early, but this isn't really ever classed as being premature. You then have very preterm, which is before 32 weeks and extremely preterm, which is before 28 weeks. So they're not necessarily terms that c come up a lot, but just in terms of your exams, just be careful of what the question says. And if it just asks for the very, in extremely preterm, it is a pain cos it is just sort of, you've got to learn the weeks, but then once you've got that it should be a nice easy mark. So in terms of prematurity, there are loads of different things that are risk factors and causes of them. It's not important to know these off by heart. So don't feel like you have to sit and learn them, but it's good to have a awareness of the different things that can cause and lead to premature labor. So I've highlighted in bold, the ones that I think are slightly more important and I've done this throughout the presentation. So if something's in bold, it's something that I think is an important thing to try and remember. So in terms of the sort of causes stuff that causes interuterine stretch can be stuff like polyhydramnios. So if there's too much fluid in multiple gestation pregnancies. So that's why twins are usually born earlier and uterine anomalies. So, if there's anything pathological with the mother's uterus, equally intrauterine bleeding. So if you get any abruption or hemorrhage, that can lead to problems leading to preterm labor and then as well fetal factors. So any congenital anomalies, any chromosomal anomalies or anything like intrauterine growth restriction can trigger a premature labor. So, the next thing is the drugs used in preterm labor. And this is a little bit more of a reproductive health thing as well. So, depending on what topic, your and what block you're on at the moment, um It, if it might, you might have come across this before, but there's sort of four main classes of drugs that we use in preterm labor. So firstly, it's antibiotics. So if mothers have come in with labor, that has er with a, when their membranes have ruptured before a significant period before they give birth, we give antibiotics just because we don't want the infection cos that can spread to the babies and the more sort of ones that I think could come up in your exam. So we use steroids. Um and these are given to babies that are under 30 well given to the mothers who have got, who are under 36 weeks gestation. And this helps reduce the rates of respiratory distress, hemorrhage and also neonatal death, then we give magnesium sulfate for any gestation under 34 weeks because this protects the fetal brain during delivery and has quite a significant reduced risk of cerebral palsy. And then we also use tocolysis, which is basically just to try to suppress the uterine contractions. And that's the main thing that I think you should take away from it. There are several different drugs used. So you can use Nifedipine, n, Nifedipine or Atosiban and they're used for any mothers are between 24 and the 34 weeks gestation, it's only used for 48 hours. So we'll never try to prolong the labor after 48 hours because that has worse risks for the baby. But it means that in this period, we can get them some steroids, we could maybe transfer to a more tertiary center. So any mothers in the region that are, that have sort of significant preterm labor, they'll try transfer up to the RV. Because the neonatal unit there is one of the biggest in the country. But obviously, sometimes we can't do that. We just have to live wherever. And in the region, we have um the neonatal transport service which is just a special ambulance that can transport the babies from all across the northeast. And they come over to Cumbria just in their incubators. So with uh OK, so um she gives birth to a baby girl who's got the following measurements. So a 37 centimeter length, a 25.3 centimeter head circumference and a 1.1 kg weight. So then what you may be asked to do in an exam, but I've done for you is to plot on a growth chart. And I know it's really hard to see this growth chart. I'll make the slides available at the end so you can have a look. But for preterm Children, we have a special growth chart that we use. So you can see at the top it's for 23 to 42 week gestation and you'll use this for any preterm babies before they move onto the standard one. And I've plotted all of the measurements forwards and they all sit behind between the second and the ninth centile. Some of them are just on the second centile line. Um and some of them are closer to the ninth centile, but they're all between that and we'll come back to a bit of growth shot stuff near the end. So small for gestational age. Um I'm gonna click back because I think I've got a poly list. Um No, so small for gestational age is another one where you've just got to learn a set of definitions. So small for gestational age is if you're below the 10th centile, so be small for gestational age is below the third centile and a low birth weight is below 2.5 kg at birth. And then there are several different causes for this one is called constitutionally small. And that's just when you match the mothers and others in the family, the growth charts actually have a picture of how you can do this and you can get the like maternal height and the paternal height and work out sort of an average in the middle of where we roughly think they can be, obviously, if you're born to parents who are both on the 10th centile themselves, then you're very likely to also be on that centile. Um Another cause is intrauterine growth restriction. Um So we will talk about that again in a minute and I'll go into that in a little bit more detail. But this is always pathological and it's to do with the amount of nutrients getting to the baby. So the main thing to remember for this one is small for gestational age can be normal. So not all babies that are small for gestational age have a pathological problem. However, babies that are diagnosed with intrauterine growth restriction is always pathological. So you can't have, it's known as IU R. You can't have that without having a pathological condition and then for intrauterine growth restriction. So this, you don't really need to know this in much detail at all. Um But it, if you are interested, it gives you a little bit of an idea about the types of effect it can have on the baby so that if it occurs early in pregnancy, they'll have a symmetrical growth. So all of the sents on the growth chart will be in a um will be in between the same centile. Um Whereas if it occurs after tw er 20 weeks of pregnancy, you start to have different aspects. So the first part, after 20 weeks, you'll get the head circumference being significantly larger than the abdominal circumference. And that's just because the body's me mechanisms to protect the brain. And then stage three, you'll just get an asymmetrical growth. So then I have another question. So at this stage, considering what we know already, what diagnosis could we give to the baby in case one? So it's small for gestational age. A sy symmetric intrauterine growth restriction, constitutionally small or an asymmetric intrauterine growth restriction. Um Yeah, the slides will be made available at the end and I'll post the feedback form at the end of the session as well. I'll just give them a little bit of time for people to do that. Paul, I'll go back. So they were the measurements for case one, if people are what the measurements. So this is a little bit of a tricky question um in terms of how I've worded it, but it's just at this stage considering what we know, which is pretty much just what's on this slide. What can we diagnose this baby with? I'll give it another minute. We've got seven responses at the moment. OK. So most of you have got that. So, yeah, so this baby um can only be diagnosed as small gestational age cos they sit below that sense, 10th centile between the 2nd and 9th. So they're always below that 10th centile. The likelihood is they might have, they might be constitutionally small or they might have a growth restriction. But at this point, we don't know that. Um So again, just make sure in an exam question, if it was to ask you about any of these, if it doesn't give you any further information about the baby, then it's likely the answer is gonna be small for gestational age. If it talks about the parents both being small or having some condition in utero, so any multiple pregnancies, anything like that, then you can look at a growth restriction. Ok. So, um so our baby now appears to be working a bit harder. So they've been born for 30 minutes and on examination, they've now got a respiratory rate of 65. They've got chest recessions, head bobbing and decreased breath sounds across all lung fields. The respiratory rate normally for babies of this age is between sort of 3060. Um So it's a lot higher than you'd get in adults, but this baby still seems to be working a little bit harder. Um And you can see the chest recessions. I don't know if this video is going to work. I don't think it is. Um Well, if you get the slides at the end, this is a really good video to show head bobbing. Um, and this is basically something that you see quite a lot in neonates and young Children and because their neck muscles are so weak when they're struggling to breathe, it makes their whole head bob and sort of move up and down this video. I've never seen any quite so, sort of pronounced as this. Normally. It's quite a lot, sort of a, um, but it's one thing to look out for and if you were in anything like the oy that came up with something like this, it would be a good thing to seeing you. So this is the chest X ray of this baby. Um And I know that a lot of you haven't done pediatrics and I wouldn't expect you to know, be able to read it neonatal chest X ray. But considering the information we know so far, what do we think the most likely diagnosis is for this baby? And I will talk through this chest X ray again in a minute. As a little bonus question. There is another abnormality with this chest X ray. And if anyone can comment, I in the group chat, I'll give it another few minutes to let people on the support. Everybody just seem to be getting the I do with this though. So apart from the, your right to say ground glass, there's another abnormality that's not related to the respiratory condition. It is really difficult. Yes. Yeah. The NG tube is not quite in the right place there. Um So you well done for game. It's quite a hard one. So, yes. So we've got a slight range of answers. So this uh this is respiratory distress syndrome. Um So on the x-ray, it's described as a ground glass appearance, um which you can sort of see with the shadowing the end you tube yet is in the wrong place. I know a couple of people said about the diaphragmatic hernia and I know you can see sort of the gas bubble, but that's completely normal in a diaphragmatic hernia. You'd expect because their whole bowel has developed outside of their abdomen, you can expect to sort of see bowel all the way up the chest wall. Um, and usually, yeah. So it is pretty hard. You can, it might be easier to see once you get the slides. I can just about see it on mine. Um, yeah. But yeah, so it's the ground glass really does distort that as well. Um, but in, for the babies that have got the diaphragmatic hernias, these are usually diagnosed prenatally. So you very rarely see them be diagnosed once a baby's born. Um, we had one last hours on my SSC and it is a complete, it's an emergency. They go pretty much immediately for surgery. Um, because because the bowels developed outside of the abdomen, it means that their lungs don't properly developed and it can affect all the mediastinum and everything as well. So the babies are usually a little bit more unwell. So just to go back to respiratory distress syndrome. So it's be it happens because there's decreased surfactant. And the reason why you see it in these preterm babies is cos the surfactant levels reach their peak at about 33 to 35 weeks. So a little bit older than when our baby is. So when you get the younger sort of lower gestational age babies, because they've not got as much as the fact and it increases the surface tension. So they can't get those alveoli opened up. So it presents pretty much exactly like our baby did fast respiratory rate, you get the recessions, you can get cyanosis as well and also decreased breath sounds, the chest X ray has the ground glass appearance. And then in terms of management, obviously, like we said earlier, you can give the steroids in for women that are in preterm labor to try and prevent it. But obviously, that's not always possible. And even if we do give the steroids, it doesn't necessarily prevent it fully. Um So it's just it, it reduces the risk that you can, it still happens. And then for these babies, we give respiratory support. So depending on how unwell they are, it depends. So some of them can just manage with nasal cannula and a bit of oxygen. Some need C A which is pretty similar to what they use in adults with COPD, it's just a continuous pressure to keep those alveoli open while they, while the babies sort of get the surfactant that they can use. And for the really sick ones, we do sometimes use mechanical ventilation and we can give surfactant via, via a tracheal tube. So that just goes down sort of alongside when they're having the CPAP, they can get that sort of artificial surfactant which then helps them get better. OK. So move on to our second case. So again, any questions um just ask, I did wanna mention with the congenital hernia, I wouldn't worry too much about that. Um So it's not one of the Newcastle core conditions. It's just something I'd be aware of. Um You again, another thing that you hear is you hear bowel sounds in the lung feels. So it's quite obvious if you hear it that you'll get that. Ok. So case two. So we've got a 28 year old female who presents to the maternity unit at 41 weeks, gestation with regular painful contractions. There's signs of cord prolapse which result in her having a Cesarean section delivery. And within 30 minutes, the baby boy begins to develop respiratory distress and lowered oxygen saturations. So this is the chest X ray and I have hopefully highlighted the abnormality in this one. So I'll do another pole and same question again. What's the most likely diagnosis for this baby? I know we've not got much of a history, but hello. Um, this is quite a classical presentation for this condition. I'll give a few minutes, just let see if I'll get a few more people to answer while I just grab a drink and then I'll review the answers. Ok. So, yeah, obviously two of them have basically been eliminated by the fact that one of them was the answer to the last job. And the second was, um, I've talked about in quite a lot of detail. Um And yet the people that have answered. So yes. So I've circled around it and again, it is really hard to see. And I think if you've got an a neonatal x-ray in a risky, it would be a really, really harsh question. Um I'm not saying it wouldn't happen. And again, it could come up on the SBA paper with an X ray asking you for the most likely diagnosis. But yeah, like people have said that you can just about see there's a sort of hairline in between those ribs and that's a fluid line in the horizontal fissure. So this is um transient tachypnea of the newborn or TTN. Um So the reason that this was quite a classical presentation is because it, it's the most common cause of respiratory distress in term infants. This baby was 41 so slightly post dates, but was also born with ac section birth, which these babies usually are. And it's basically just a delay in the lung fluid reabsorbing, which is why it's more common after the C section. Because during a vaginal delivery, the fluid is sort of squeezed out a little bit more. Whereas in the C section you don't get, it's more of a sudden change in pressure. So that doesn't necessarily happen. It usually settles on its own within the first sort of day of life. Some of these babies need a bit of oxygen and some of them need a bit of feeding support just because the low oxygen levels can mean they don't really want to feed. And obviously when you've got a newborn, you want to make sure you're getting those calories in as soon as possible. I see. Yeah, you get the fluid level in the right right lung in the horizontal fissure and the same as my other slides. Anything in bold is the things that I think is sort of important for your exam. So cos there are quite a few conditions where the babies are born with respiratory issues. Um I do have a summary slide at the end as well. Um which should help. But yeah, just remember if it's a turn baby and it's been born by ac section, they're having respiratory distress and they're not systemically unwell. So they don't have a fever. Um They don't, they're not struggling sort of in a more serious way that might suggest a hernia or something like that. Then you're probably looking at this. So this baby is very unlucky. And after a few days monitoring in the hospital, they have a seizure which is self resolving, but um they still have a seizure. So, does anyone have any differentials for what this could be? I've not got a poll for this one. But if you wanna just type in the chat any differentials, this is quite a tenuous link and you wouldn't necessarily get a baby that has TTN and then this next condition at the same time. Um But we this one's been unlucky. I'll just give another minute to see if anyone's got any ideas. Yeah, that could be one. That isn't the answer for this one. But yeah, it could be. Yep. Well done. Alfie. Um So yeah, so this is meant to be a case of hie or hypoxic ischemic encephalopathy. Um which again is one of those conditions that they want you to know about, um is not all that common. Um But I've highlighted again, anything important. II forgot a poll for this one. So basically, it's, it can be caused like anything causing an oxygen shortage around the time of birth. Obviously, this baby had a cord prolapse, which was the sort of hint that there was an oxygen shortage. Um And it usually, it usually presents fairly quickly after birth. Um I've got some classification on the next slide which I'll go through. Um But the main thing for this one, which I think is sort of the one of the more likely things to come up in your exams is that the management for it is therapeutic hypothermia. So they lower these baby's core temperatures to 33 to 34 degrees for 72 hours. They only do it for babies over 36 weeks, gestation and basically this slows the inflammatory cascade down. Um and it improves the outcomes for these kids. The prognosis is really variable. So some have an absolute full recovery, no sort of long term outcomes at all. Others might have a slight developmental delay, some get cerebral palsy. Um So cerebral palsy is correct me if I'm wrong, but I'm cerebral palsy is the any insult that occurs sort of before the age of two and it is damaging to the neurons in the brain that are still developing. The myelin is defined as cerebral palsy. So it's not all prenatal. Obviously, in this for hie, it is just sort of around the sort of birth period when it happens. But then some babies can also die from hie um depending on how much oxygen is depleted around the time of birth, it can be quite serious. So in terms of the classification, you don't need to know this, so don't worry about learning it in detail, but there is a range. So you can get the mild, they're a bit, babies are a little bit irritable, you might get some staring and they might respond a little bit excessively. So they might startle quite a lot to any like, quiet noises or if they're picked up, they might be quite more active than you'd expect a baby of that age to be. Obviously at mild, a lot of the time, this can just go unnoticed because you wouldn't necessarily think that your baby is being specifically irritable when it's just been born. Um, but then as you get more severe, you can get sort of a lack of any spontaneous movement, you can get prolonged seizures and the organ failure, obviously, the more severe down the line, the more likely of the worse outcomes um later on. So I have a pa so which of the following is least likely to lead to hypoxic ischemic encephalopathy. Bit of a mix of two. So, yeah, so you try to rupture prolapse cause and percent abruption all easily have a chance of doing it cos it's gonna cause the oxygen charge for the baby. Um, shoulder dystocia can, it is, it's probably less likely than the other three, but it can just because because the baby gets stuck, they can not be able to breathe during that time, but the least likely is gestational diabetes. Um I'm sure there are some situations where it can happen. But compared to the others, you're much less likely to see it happening in a diabetic patient compared to one that's had a prolapsed cord. Ok. And then moving on to our last condition, which is meconium aspiration. So I didn't put this one into a case. Um Just cos it was the last one left. Um But basically for this one, again, it's the older the baby is sort of gestationally, the more likely it is to happen. So, if you've got a baby that's born at 42 weeks or later, you'd be expecting it more. And a lot of the reason why is it's again in a response to fetal hypoxia. So the baby will have low oxygen which causes them to pass the meum while still in utero. Um which then means that they can aspirate it because it's staining the amniotic fluid. So that's how it presents. So you'll get a meconium stained amniotic fluid. Um The skin will be a sort of green yellow tinge when they're born and they also get the respiratory distress. Um The chest X ray will be sort of bilateral patchy changes. Um So not quite like R DS or TTN. So with TTN, you get the fluid line and R DS, it's sort of all throughout. It's more, it's very much more patchy and the management for this is really supportive. Most babies sort of solve themselves of it just over time. Um But some, depending on sort of the amount of meconium they've aspirated, might need mechanical ventilation and then complications. It can cause a pneumothorax and a pneumomediastinum and it can lead to persistent pulmonary hypertension of the newborn which isn't um which isn't one of your core conditions. Um but it pretty much as it sounds, they just you get the pulmonary hypertension. Ok. So I have, so I've, I've done my questions slightly out of order. Um So yeah, so that's that one and then I have one more question uh I will send out now. So which condition and we have just spoken about this? So I think it will be fairly quick, but which condition is most likely to lead to an X ray with a grand glass appearance? So, TTN sepsis R DS meconium aspiration or is it seen in a healthy neonate? Yeah. So I've had seven responses but most of you getting, you get that ground glass appearance. So the last thing that I wanted to show you is just this slide. So the arrows have slightly gone a little bit haywire. But in terms of your exams, obviously, these conditions all can blur into one and seem very similar. So I've tried to break it down as to how in an exam, if you get a baby with respiratory distress, how if you were really struggling, you could work out what was going on. So if you split it up in two term and preterm babies, so I have the, the hernia can be both. Um But for preterm and term, like I say, that's usually diagnosed prenatally. So I highly doubt you'd get a question on that but if you've got anything about hearing bowel in the lung field, um that says bowel visible in the abdomen, that should say bowel visable in the chest. Um But for your preterm babies, then your main thing is either if you get an X ray with a ground glass appearance, it's going to be R DS. If you get a baby who's really systemically unwell with a fever, there might have been a maternal infection as well, then that's gonna be an infection or sepsis or something along those lines. And then if you've got a term baby that's had a Cesarean section, it's going to be TTN. And if you've had a turn baby who's passed meconium during delivery, it's gonna be meconium aspiration. The all of these topics are quite specialist ones um that you're not really ever gonna be dealing with as an F one. not on your own, especially. So they just want you to be able to know the basics and basically just be able to recognize them. So if you can recognize that baby's been born by AC section and it's at term they've, and they've got respiratory distress, it's probably gonna be TTN. So just try not worry too much about all of the different details. If you can get the chest X ray for each condition and sort of the classical presentation, then you should do absolutely fine. So that is the, all I've got for today, I'll just stop sharing and I'll send the feedback form. So if you fill in the feedback form, um you'll get access to the slides. Um And um I think you get a certificate for attending as well. Um If you attend three sessions throughout this series and are also a member of the Newcastle Pediatric Society, we have a prize draw for some um pediatric textbooks. The second half of the neonatal topics will be covered again tomorrow. Um So if you are interested, the topics tomorrow that I'll be covering is neonatal hypoglycemia, neonatal jaundice, neonatal sepsis, hemolytic disease of the newborn congenital heart disease and necrotizing enterocolitis. Um So today's been more of a neonatal respiratory and tomorrow will be everything else. Um I know there are a lot of core conditions linked to neonates and babies and I know that it can be really scary because they are so small. Um But it's once you sort of break them down, it's not that complicated and you should be able to pick up the marks in the exam. Um And yeah, like I said, if anyone's interested in doing any sort of neonatal SSC, I'll pop my email in the chat um and feel free to give me a message about it and I can let you know. But other than that, thank you. And yeah, please fill out the feedback form
