Paediatrics Marrow Pg 11-20 (Neonatology)

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Questions and Answers

Which organism is the most common cause of neonatal sepsis in India?

Group B Streptococcus

E. coli

S. aureus

Klebsiella (correct)

Late onset sepsis occurs in the first 72 hours of life.

False

Name one risk factor for early onset sepsis.

Unclean hands of health professionals

Signs of meningitis in a newborn can include fever and __________.

irritability Signup and view all the answers

Match the types of neonatal sepsis with their characteristics:

Early onset sepsis = Occurs within the first 72 hours Late onset sepsis = Occurs after 72 hours Generalized sepsis = Affects multiple organ systems Localized sepsis = Specific to one organ system Signup and view all the answers

What is the initial step to take when risk factors are present for a neonate suspected of early-onset sepsis?

Start antibiotics Signup and view all the answers

For late-onset sepsis in neonates, if symptoms are absent, lumbar puncture is required.

False Signup and view all the answers

What procedures should be performed when symptoms of sepsis are present in a neonate with late-onset sepsis?

Close monitoring, antibiotics, blood culture, lumbar puncture Signup and view all the answers

In case of suspected early-onset sepsis with no symptoms, it is advised to perform __________.

no lumbar puncture Signup and view all the answers

Match the following aspects of sepsis management with their corresponding situations:

Start antibiotics = Risk factors present for early-onset Perform LP = Symptoms present for early-onset Close monitoring = Symptoms absent for late-onset Sepsis screen = Not sick baby Signup and view all the answers

What is the gold standard test for investigating sepsis?

Blood culture Signup and view all the answers

All symptomatic babies suspected of meningitis should undergo a lumbar puncture.

True Signup and view all the answers

What is the treatment duration for culture-negative sepsis?

5-7 days Signup and view all the answers

The newest marker for neonatal screening is increased __________.

procalcitonin Signup and view all the answers

Match the clinical scenario in sepsis with its appropriate treatment:

Low resistance, suspected meningitis = Ciprofloxacin + Amikacin High resistance, suspected meningitis = Penicillin + Aminoglycoside Culture negative = 5-7 days of treatment Culture positive = 3 weeks of treatment Signup and view all the answers

What percentage of newborns is affected by neonatal jaundice?

60% Signup and view all the answers

Physiological jaundice in newborns typically requires treatment.

False Signup and view all the answers

What is the best investigation for assessing jaundice in newborns?

Serum Bilirubin Levels Signup and view all the answers

In Kramer zones, the danger sign that indicates risk of Kernicterus appears in Zone ______.

5 Signup and view all the answers

Match the following Kramer zones with their appropriate serum bilirubin levels:

Zone 1 = 5-7 mg/dL Zone 2 = 7-9 mg/dL Zone 3 = 9-11 mg/dL Zone 4 = 11-13 mg/dL Zone 5 = >13-15 mg/dL Signup and view all the answers

What is a significant contributing factor to respiratory distress in newborns?

Preterm birth Signup and view all the answers

Preterm infants are at an increased risk of developing respiratory distress.

True Signup and view all the answers

Name one complication that can arise from respiratory distress in newborns.

Hypoxia Signup and view all the answers

Respiratory distress due to preterm birth can be primarily associated with __________ immaturity.

pulmonary Signup and view all the answers

Match the following conditions with their descriptions related to newborns:

Respiratory distress syndrome = Commonly seen in preterm infants due to surfactant deficiency Transitional respiratory distress = Occurs within the first few hours after birth Meconium aspiration syndrome = Results from inhaling meconium-stained amniotic fluid Pneumothorax = Presence of air in the pleural space affecting breathing Signup and view all the answers

What is a normal respiratory rate for a newborn?

40-60 breaths/min Signup and view all the answers

Severe hypoxia in newborns can present with central cyanosis.

True Signup and view all the answers

What does grunting in a newborn signify?

Expiration against a partially closed glottis Signup and view all the answers

A newborn exhibiting see-saw respiration has ________ chest retraction.

severe Signup and view all the answers

Match the criteria of the Downe's score with their descriptions:

Cyanosis = Not present Respiratory rate = 80/min Air entry = B/L equal & normal Retractions = Not present Grunting = Not heard Signup and view all the answers

Which stage of necrotizing enterocolitis is characterized by gross blood in stools?

IB Signup and view all the answers

Stage III a includes induration, redness, and tenderness.

True Signup and view all the answers

What is the primary management intervention for a neonate in stage III b of necrotizing enterocolitis?

Peritoneal drainage Signup and view all the answers

A triad of lab findings indicated for necrotizing enterocolitis includes thrombocytopenia, metabolic acidosis, and __________.

hyponatremia Signup and view all the answers

Match the stages of necrotizing enterocolitis with their descriptions:

IA = Occult blood in stools III b = Intestinal perforation II b = Absent bowel sounds + abdominal wall edema II a = Absent bowel sounds Signup and view all the answers

Which of the following is NOT a consequence of Meconium Aspiration Syndrome (MAS)?

Pulmonary hypoplasia Signup and view all the answers

Meconium Aspiration Syndrome is diagnosed primarily through imaging studies.

False Signup and view all the answers

What is one of the management strategies for severe cases of Meconium Aspiration Syndrome?

Mechanical ventilation Signup and view all the answers

Congenital Diaphragmatic Hernia is characterized by an anatomical defect in the __________.

diaphragm Signup and view all the answers

Match the type of diaphragmatic hernia with its location:

Morgagni = Antero-medial diaphragm Bochdalek = Posterolateral diaphragm Signup and view all the answers

Which condition is the most common cause of respiratory distress in newborns?

Transient tachypnea of newborn Signup and view all the answers

Transient tachypnea of newborn is more common in neonates delivered by lower segment caesarean section.

True Signup and view all the answers

What is the common time frame for improvement in transient tachypnea of newborn?

48-72 hours Signup and view all the answers

Fluid in the interlobar fissure is a common chest X-ray finding in __________.

transient tachypnea of newborn Signup and view all the answers

Match the following conditions with their respective management strategies:

Transient tachypnea of newborn = Supportive management with O2 inhalation Respiratory distress syndrome = Surfactant therapy Meconium aspiration syndrome = Airway suctioning General respiratory distress = CPR if necessary Signup and view all the answers

Which of the following is a contraindication for bag and mask ventilation in congenital diaphragmatic hernia (CDH)?

Congenital diaphragmatic hernia Signup and view all the answers

The onset of respiratory distress in a newborn with CDH after 24 hours indicates a better prognosis.

False Signup and view all the answers

What is the first step in managing a newborn who does not cry at birth?

Resuscitation Signup and view all the answers

The respiratory condition diagnosed by the presence of intestines in the thorax is called __________.

congenital diaphragmatic hernia Signup and view all the answers

Match the following prognostic factors of congenital diaphragmatic hernia with their implications:

Lung-head ratio < 1 = Bad prognosis PPNH present = Bad prognosis Onset of respiratory distress < 24 hours = Bad prognosis Unaffected lung considered = Good prognosis Signup and view all the answers

Study Notes

Sepsis Algorithm

Early Onset Sepsis (Age < 72 hrs):
- Risk Factors Present: Start antibiotics, blood culture, close monitoring.
- Symptoms Present (Lumbar Puncture): Perform LP.
- Symptoms Absent (Lumbar Puncture): No LP.
Late Onset Sepsis (Age > 72 hrs):
- Risk Factors Present:
  - Symptoms Present: Close monitoring, antibiotics, blood culture, lumbar puncture.
  - Symptoms Absent: Close monitoring.
- Risk Factors Absent:
  - Not Sick: Sepsis screen.
  - Sick Baby: Sepsis screen.

Spectrum of neonatal sepsis

Generalized/Septicemia:
- Respiratory System: Pneumonia.
- CNS: Meningitis.
- Bones & Joints: Osteomyelitis, Arthritis.
Localized/Specific:
- Respiratory System: Pneumonia.
- CNS: Meningitis.
- Bones & Joints: Osteomyelitis, Arthritis.

Early Onset Sepsis

Source of Infection: Chorioamnionitis, infection of maternal genitalia (foul-smelling liquor), rupture of membranes over 72 hours (Pneumonia > Sepsis).
Risk Factors: Unclean hands of health professionals and caregivers, low birth weight (LBW) → reduced immunity, lack of breastfeeding.

Late Onset Sepsis

Source of Infection: Hospital acquired infection, unclean hands of health professionals and caregivers, low birth weight (LBW) → reduced immunity, lack of breastfeeding.

Organisms Implicated

India: Klebsiella (most common), Acinetobacter, S.aureus.
Worldwide: Group B Streptococcus (GBS), E.coli, Listeria.

Symptoms

Non-specific symptoms: Suspect sepsis in any sick baby due to weak immune response.
Recognized Symptoms (Early symptoms): Change in feeding pattern, lethargy, hypothermia → fever, pneumonia, respiratory distress.
Signs Specific to Organ Systems: Meningitis: Fever and irritability (non-specific), seizures.

Management

Investigations:
- Blood culture: Gold standard, time-consuming.
- Sepsis screen: Presence of >2 findings.
- Lumbar puncture (Indication): Suspicion of meningitis in all symptomatic babies.
Empirical antibiotics (while awaiting culture reports):

Clinical scenario	Treatment
Low resistance (Suspected meningitis)	Penicillin (Gram +ve cover) + Aminoglycoside (Amikacin/gentamicin)
High resistance (Suspected meningitis)	Ciprofloxacin (+Amikacin) or Piperacillin Tazobactam + amikacin (m/c)

Duration of treatment:
- Culture negative: 5-7 days (1 week).
- Culture positive: 3 weeks.
- Others: 2 weeks.

Components and Values in Sepsis

Component	Value in Sepsis
Total leukocyte count	↓ ( 15 mm/hr)
CRP	↑ (> img/dL)

Newest marker for neonatal screening: Increased procalcitonin.

Neonatal Jaundice

Incidence: Seen in up to 60% of newborns.
Pathological: 5-10% (require treatment).
Physiological: Majority (no treatment required).

Bilirubin Metabolism

Breakdown of RBCs: Haem → Biliverdin → Unconjugated bilirubin (water insoluble)
Unconjugated bilirubin: Conjugated bilirubin (in liver) (water soluble).
Conjugated bilirubin: Through bile duct → intestines.
Stercobilinogen (in colon): 90% Excreted in stools.
Urobilinogen: 10% Excreted in urine.
Enterohepatic circulation:

Assessment of Jaundice

Serum Bilirubin Levels: Best investigation, Bilirubin values: Total serum bilirubin (TSB).
Screening of Baby: Initial clinical assessment, Kramer method: Visual assessment.

Kramer Zones

Zone	Description	Appropriate Serum Bilirubin
1	Face & neck (Seen first in the eyes)	5-7 mg/dL
2	Chest & upper abdomen	7-9 mg/dL
3	Lower abdomen & thighs	9-11 mg/dL
4	Legs, arms & forearms	11-13 mg/dL
5	Palms & soles (Danger sign)	>13-15 mg/dL → Risk of Kernicterus (Brain injury)

Respiratory Distress in Newborn

Respiratory rate: Increased (>60 breaths/min.), normal newborn respiratory rate: 40-60 breaths/min.
Chest retraction: Due to involvement of accessory respiratory muscles.
Severe hypoxia: Seen in severe cases.
- Manifestations: Central cyanosis (involves mucosa), Grunting (expiration against a partially closed glottis → prevents airway/alveolar collapse).

Monitoring of Respiratory Distress

Scoring Systems

Silverman Anderson Score (Used for Preterm Babies)

Criteria	0	1	Severe (2)
1. Upper chest retraction	Synchronized respiration b/w chest & abdomen	Lag: Chest lags behind abdomen during inspiration	See-saw respiration: Chest retracts, abdomen expands during expiration
2. Lower chest retraction	Not seen	mild	Severe
3. Nasal flaring	Not seen	mild	Severe
4. Xiphoid retractions	Not seen	mild	Severe
5. Grunting	Not present	Audible with stethoscope	Audible without stethoscope
Interpretation:	7: Severe

Downe's Score (Used for Term & Preterm Babies)

Criteria	Mnemonic (CRARG)	0	1	Severe (2)
Cyanosis	C	Not present	Present in room air	Present even with O2 support, FiO2 ≥ 40%
Respiratory rate	R	80/min
Air entry	A	B/L equal & normal	Decreased	Severely decreased
Retractions	R	Not present	mild	Severe
Grunting	G	Not heard	Audible with stethoscope	Audible without stethoscope
Interpretation:	7: Severe (Impending respiratory failure)

Necrotizing Enterocolitis & Neonatal Sepsis

Features

Stage	Description
IA	Occult blood in stools
IB	Gross blood in stools
II a	Absent bowel sounds
II b	Absent bowel sounds + abdominal wall edema
III a	Induration, Redness/erythema, Tenderness
III b	Intestinal perforation

Imaging

Stage	Description
	Normal
	Pneumatosis intestinalis (Characteristic of NEC)
	Air in the intestinal wall, enters venous drainage system
	Superior mesenteric vein
	Portal vein: Pneumatosis portal vein

Management

Triad of lab findings: Seen only after stage II b. Do not have great relevance in diagnosis.
Until stage III a: Medical management - Nil per oral (NPO), total parenteral nutrition (TPN), IV antibiotics:
- Penicillin + Aminoglycosides + metronidazole (Gram+ve) (Gram-ve) (Anaerobes).
Stage III b:
- Hemodynamically unstable: Peritoneal drainage (Emergency procedure).
- After stabilization: Laparotomy → Resection & Anastomosis.
Untreated: m/c cause of neonatal mortality.
Duration of antibiotics:
- Stage Ia: 3 days.
- Stage Ib: 7-10 days.
- Stage II, III a: 14 days.

Causes of Respiratory Distress

Respiratory Distress (Onset within 6 hours of birth)

Transient tachypnea of newborn (m/c overall).
Respiratory distress syndrome.
Meconium aspiration syndrome.

Transient Tachypnea of Newborn (TTNB): (AKA wet lung syndrome)

Most common in: Term neonates, neonates delivered by lower segment caesarean section (LSCS).

Pathogenesis

Inadequate stimulation and compression at birth canal.
Delayed clearance of lung fluids.

Chest X-ray findings

Perihilar radio-opaque streaks.
Fluid in the hilum of the lung moves into bronchovascular structures.
White streaks on X-ray (AKA sunburst appearance).
Fluid in the interlobar fissure.

Management

Supportive management (O2 inhalation) - Sufficient as it is transient.
Improvement seen in 48-72 hours.

Respiratory Distress Syndrome: (AKA hyaline membrane disease (HMD))

Most common in: Preterm babies ( # Meconium Aspiration Syndrome (MAS)

Pathogenesis

Post-term baby (>42 weeks).
IUGR baby.
Birth stress.
Meconium expulsion before birth.
Aspiration of meconium-stained liquor (MSL).

Consequences of MAS

Atelectasis: Due to complete airway obstruction.
Air trapping: Difficulty expiring air due to partial airway obstruction.
Hyperinflation of lung/obstructive emphysema:
Chemical pneumonitis: Inflammatory response to meconium.
Inactivation of surfactant:
Impaired gas exchange:
Hypoxia, hypercapnia:
Chronic pulmonary vasoconstriction:
Persistent pulmonary hypertension (PPHN):

Chest X-ray findings

Infiltrates in lung fields, seen in chemical pneumonitis.

Diagnosis

MAS is diagnosed by exclusion, with a history of meconium-stained liquor.

Management

Supportive management: Oxygen (O2) inhalation, Continuous Positive Airway Pressure (CPAP).
Mechanical ventilation (severe cases).
Inhaled nitric oxide (iNO): Pulmonary vasodilator to treat PPHN.

Congenital Diaphragmatic Hernia (CDH)

Pathogenesis

Anatomical defect in the diaphragm.

Clinical Features

Respiratory distress: Lung compression in the uterus due to movement of intestines into the mediastinum.
Pulmonary hypoplasia.

Types of Diaphragmatic Hernias

Morgagni: Antero-medial diaphragm.
Bochdalek (most common): Posterolateral diaphragm.
(Note: The image description is included here but it was not possible to convert the diagram into a table or format it as intended.)*

Clinical Presentation

Mediastinal shift: Heart sound heard on the right side.
Sunken/scaphoid abdomen.

Investigations

USG (Antenatal):
Chest X-ray (Postnatal): Intestinal air shadows (air-filled bubble-shaped shadows due to bowel), absent diaphragm shadows on the affected side.

Management

If the baby does not cry at birth: Resuscitation.
If the baby cries at birth:
- Medical management (First 48 hours): Intestinal decompression via NG tube → Lung compression, mechanical ventilation via endotracheal tube → Lung expansion.
- Surgical management ( >48 hours): Hernia repair.

Contraindications

Congenital diaphragmatic hernia (CDH): Absolute contraindication for bag and mask ventilation. Cause: Forceful entry of air into the esophagus → Inflation of bowel loops → Further compression of lungs.

Prognostic Factors of CDH

Antenatal USG:
- Lung-head ratio (LHR): < 1: Bad prognosis.
Postnatal:
- PPNH (most important): Bad prognosis.
- Onset of respiratory distress < 24 hours: Bad prognosis.
- Presence of liver in the thorax: Bad prognosis.
- Unaffected lung to be considered.
(Note: This document describes congenital diaphragmatic hernia (CDH) in newborns, including its presentation, investigations, management, contraindications, and prognostic factors. A chest X-ray image is part of this assessment.)*

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Test your knowledge on the sepsis algorithm for neonates, specifically focusing on early and late onset sepsis. This quiz covers risk factors, symptoms, and recommended actions for managing sepsis in newborns. Enhance your understanding of this critical clinical topic.