 14 Neonatal SBA

September 2021

The Royal College of

Emergency Medicine

MRCEM INTERMEDIATE SBA

SEPTEMBER 2021

14 Neonatal
SBA

Collected by Dr. Haitham Khalil September 2021

 Neonatal Emergencies  QUESTION 1

A 36 year old woman presents to the Emergency Department in active labour. Shortly after her arrival in the ED a
baby boy is delivered. He is pale, floppy and unresponsive. You progress through neonatal life support and begin to
start chest compressions as indicated. What is the recommended compression to ventilation ratio in neonatal life
support?

✓ 3:1 60%

5:1 5%

x 10:2 3%

15:2 27%

30:2 6%

ANSWER
The ratio of compressions to inflations in newborn resuscitation is 3:1.
 Neonatal Emergencies  QUESTION 2

A newborn baby girl is brought to the Emergency Department as her mother is concerned she has turned yellow. On
examination you note jaundice of the skin and sclera. What complication is of most concern in neonatal jaundice?

✓ Kernicterus 85%

Sepsis 7%

Dehydration 4%

x Cardiomyopathy 2%

Weight loss 2%

ANSWER
Kernicterus is a term used to describe the clinical features of acute or chronic bilirubin encephalopathy and the pathological findings of deep
yellow staining in the brain. Babies with hyperbilirubinaemia are at increased risk of developing kernicterus if they have any of the following: a
serum bilirubin level greater than 340 micromol/litre in babies with a gestational age of 37 weeks or more, a rapidly rising bilirubin level of greater
than 8.5 micromol/litre per hour or clinical features of acute bilirubin encephalopathy.
 Neonatal Emergencies  QUESTION 3

A mother presents to the Emergency Department with her male newborn.

She tells you she delivered him at home 16 hours ago at term. His mother is
concerned that since delivery he has become increasingly jaundiced. His
observations are recorded as:
Heart rate: 154 beats per minute
Respiratory rate: 30 breaths per minute
Temperature: 36.9°C
The neonatal team perform a blood film which shows Heinz bodies. What is
the most likely diagnosis?

Physiological jaundice 8%

Breastmilk jaundice 3%

✓ Glucose-6-phosphate-dehydrogenase deficiency 80%

Biliary atresia 4%

Sepsis 5%

ANSWER
Jaundice presenting within the first 24 hours is almost always pathological. Heinz bodies are
clumps of damaged haemoglobin located on red blood cells seen in haemolytic anaemia.
Glucose-6-phosphate-dehydrogenase deficiency is a familial enzyme disorder of red blood
cells. The clinical presentation of G6PD deficiency includes a spectrum of haemolytic anaemia
ranging from mild to severe haemolysis in response to oxidative stress.

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Neonatal Emergencies  QUESTION 4 >

A 16 year old girl self presents to the Emergency Department in active labour. She has been
concealing the pregnancy from her parents. Shortly after arrival a baby boy is delivered. Five minutes
after delivery his observations are recorded:
Heart rate: 130 beats per minute
Cyanotic hands and feet
Good muscle tone
Strong cry when stimulated
What is his APGAR score?

6 20%

7 33%

x 8 16%

✓ 9 27%

10 5%

ANSWER

Sign/Score 0 1 2
Appearance (colour) Pale blue Body pink, extremities blue Completely pink
Pulse rate Absent < 100 > 100
Grimace (reflex irritability) No response to stimulation Grimace when stimulated Cries when stimulated
Activity (muscle tone) Limp Some flexion of extremities Active
Respiratory effort Absent Slow/irregular Strong cry

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 Neonatal Emergencies  QUESTION 5

A 3 day old baby boy is brought to the Emergency Department by his parents.
They are concerned he is irritable and not feeding well. He was born by normal
vaginal delivery and mother and baby were discharged after 24 hours. His
observations are recorded as:
Heart rate: 145 beats per minute
Respiratory rate: 30 breaths per minute
Central capillary refill: 2 seconds
Oxygen saturations: 97% on air
Temperature: 33.4°C
On examination you note he is drowsy but can be roused with gentle stimulus.
Your examination is otherwise normal. What is the most likely diagnosis?

Congenital heart disease 9%

Hypernatraemia 4%

Hyponatraemia 8%

✓ Sepsis 70%

Still's disease 9%

ANSWER
Neonates have poor thermoregulatory mechanisms, and neonatal hypothermia is relatively common
after precipitous delivery. However, with proper care, the hypothermia resolves and does not cause
long-term problems. Hypothermia 72 hours after birth is frequently caused by sepsis. A full septic
evaluation is indicated in this case. Neonatal hypothermia is also associated with hypoglycemia and
child neglect or abuse. Poor feeding and dehydration can result in hypernatraemia, whereas dilution
of infant formula can result in hyponatremia. Neither should result in hypothermia. Congenital heart
disease frequently presents with distress during feedings but, similarly, should not result in
hypothermia. Still’s disease is a rare rheumatologic disease associated with fever, arthralgia, and
rash.
 Neonatal Emergencies  QUESTION 6

A newborn baby boy is brought to the Emergency Department as his mother is concerned he has turned yellow. On
examination you note jaundice of the skin and sclera. Jaundice is most likely to be physiological in a term infant in
which of the following cases?

Jaundice at 12 hours of age 9%

✓ Serum bilirubin level increasing less than 5 mg/dL/24 hours in first 2-4 days 64%

Direct serum bilirubin greater than 2 mg/dL 5%

x Jaundice at 13 days of age 10%

Serum bilirubin level 15 mg/dL at 7 days of age 11%

ANSWER
Physiological jaundice can occur in breastfed and formula-fed babies and results from increased bilirubin load, decreased uptake by the liver,
decreased conjugation in the liver, and decreased excretion into bile. Physiological jaundice usually appears at 2 days of age, peaks on days 3 to 5,
and then decreases, usually by around day 10.
 Neonatal Emergencies  QUESTION 7

A 16 year old girl self presents to the Emergency Department in active labour. She has been concealing the pregnancy from her
parents. Shortly after arrival a baby boy is delivered. You have dried, warmed and stimulated the baby and placed him in a neutral
position. The baby is not breathing. You give 5 inflation breaths and see chest movement. No heart rate is recorded. What is the next
management step?

Immediately start chest compressions 45%

✓ Continue to ventilate for 30 seconds and reassess 47%

Immediately give IV adrenaline 4%

x Intubate and provide positive-pressure ventilation 3%

Intubate and apply negative-pressure suction 2%

ANSWER

When the chest is moving:

If heart rate is not detectable or very slow (< 60/min), ventilate for 30 seconds
Reassess heart rate:
If heart rate is still < 60/min, start chest compressions, coordinating with ventilation breaths in a ratio of 3:1
Reassess heart rate every 30 seconds:
If heart rate is not detectable or very slow (< 60/min), consider venous access and drugs
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Neonatal Emergencies  QUESTION 8 >

A 27 year old woman presents to the Emergency Department complaining of 1 minute episodes of
abdominal pain occurring every 3-5 minutes. Her abdomen appears swollen and you consider the
possibility of the patient being in labour. The patient denies being pregnant however an ultrasound
confirms she is indeed pregnant. Maternity and neonatal services are located at another site across
the city. Before transfer can be arrange the baby starts crowning and is delivered in the Emergency
Department. The baby appears to be term. The on-call neonatologist is on the phone and asks you to
calculate the APGAR score. Which feature is NOT part of the APGAR score?

Skin colour 2%

Pulse rate 5%

Muscle tone 4%

✓ Oxygen saturations 83%

Reflex to stimulation 7%

ANSWER

Sign/Score 0 1 2
Appearance (colour) Pale blue Body pink, extremities blue Completely pink
Pulse rate Absent < 100 > 100
Grimace (reflex irritability) No response to stimulation Grimace when stimulated Cries when stimulated
Activity (muscle tone) Limp Some flexion of extremities Active
Respiratory effort Absent Slow/irregular Strong cry

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Neonatal Emergencies  QUESTION 9 >

A 3 day old boy is brought to the Emergency Department by his mother. She
has noticed that he has become jaundiced. He is otherwise well and feeding
well. What is the most common cause of jaundice in the neonate?

Blood group incompatibility 4%

Breastmilk jaundice 10%

✓ Physiological jaundice 83%

x Gilbert's syndrome 1%

Toxoplasmosis, other (congenital syphilis and viruses), rubella, cytomegalovirus, 2%

and herpes simplex virus (TORCH) infection

ANSWER
Although each of these may be a cause of hyperbilirubinemia in the newborn, the most
common cause of jaundice is physiological jaundice of the newborn. Physiological jaundice can
occur in breastfed and formula-fed babies and results from increased bilirubin load, decreased
uptake by the liver, decreased conjugation in the liver, and decreased excretion into bile.
Physiological jaundice usually appears at 2 days of age, peaks on days 3 to 5, and then
decreases, usually by around day 10.

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 Neonatal Emergencies  QUESTION 10

A 3 day old baby boy is brought to the Emergency Department by his

mother. She has noticed that he has become jaundiced. He is otherwise well
and feeding well. Which of the following is a risk factor for neonatal
jaundice?

Female sex 2%

✓ Prematurity 80%

Bottle feeding 11%

x Gastroesophageal reflux disease 2%

Maternal age younger than 25 years of age 5%

ANSWER
Babies more likely to develop significant hyperbilirubinaemia include those with the following
factors:

Gestational age under 38 weeks

A previous sibling with neonatal jaundice requiring phototherapy
Visible jaundice in the first 24 hours of life
A mother's intention to breastfeed exclusively
Visible bruising
Cephalhaematoma
Male sex
Maternal age older than 25 years of age
Maternal diabetes mellitus
Asian, European, or native American ethnicity
Dehydration

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 Neonatal Emergencies  QUESTION 11

A baby is delivered in the Emergency Department at 42 weeks gestation with thick meconium-stained fluid. The baby
is hypotonic, cyanotic, apnoeic and bradycardic. What is the first management step for this baby?

✓ Warming, drying and stimulation 76%

Administer adrenaline 2%

Provide positive-pressure bag and mask ventilation 10%

x Intubate and provide positive-pressure ventilation 5%

Intubate and apply negative-pressure suction 7%

ANSWER
For infants born with meconium-stained amniotic fluid, routine intubation and endotracheal tube suctioning are no longer recommended because
they have shown no consistent benefit. Infants born through even thick meconium should instead have gentle mouth suctioning, if needed,
followed by warming, drying, and stimulation.
 Neonatal Emergencies  QUESTION 12

A 1 week old baby boy is brought to the Emergency Department by his parents. They have noticed he turns blue
when feeding. On examination you find a murmur. You suspect one of the cyanotic congenital heart defects. Which
of the following is a cyanotic congenital heart defect?

Coarctation of the aorta 5%

x Atrial septal defect 4%

Ventricular septal defect 12%

✓ Tetralogy of Fallot 78%

Aortic stenosis 2%

ANSWER
Aortic stenosis, ASD, coarctation of the aorta, and VSD are all considered acyanotic CHDs. The classic cyanotic CHDs can be remembered by the
“five Ts”: truncus arteriosus, transposition of the great arteries, tricuspid atresia, tetralogy of Fallot, and total anomalous pulmonary venous return.
 Neonatal Emergencies  QUESTION 13

You have been asked to give a teaching session to a group of medical students and you are discussing neonatal
resuscitation. Most neonatal deliveries that require resuscitation are corrected by which of the following
management steps?

Administering fluids 1%

Administering glucose 1%

x Bag-mask ventilation 10%

Intubation 1%

✓ Warming, drying and stimulation 87%

ANSWER
Drying, warming, positioning, and stimulating the infant are usually sufficient resuscitative measures in most deliveries.

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 Neonatal Emergencies  QUESTION 14

You are assessing a 3 week old boy who has been brought to the Emergency Department by his mother. She is
concerned that he appeared to become blue while feeding. The paediatric consultant is concerned about a possible
diagnosis of tetralogy of Fallot. Which of the following increases the systemic vascular resistance (SVR) thus
producing a left-to-right shunt through the ventricular septal defect (VSD) associated with tetralogy of Fallot?

Acute hypovolaemia 8%

Crying 29%

Defaecation 6%

✓ Squatting 49%

Tachycardia 7%

ANSWER
Squatting or knee-to-chest positions increase the SVR, thus improving tet spells by producing the left-to-right shunt. Acute hypovolaemia,
crying, defaecation, and tachycardia are all events that suddenly lower the SVR and produce large right-to-left shunts across the VSD, beginning
the vicious cycle of a hypoxic (“tet”) spell.
 Neonatal Emergencies  QUESTION 15

An 8 day old baby girl is brought to the Emergency Department by her parents. They are concerned as she has lost
15% of her birth weight and has become yellow in colour. They also describe "chalky stools". What is the most likely
diagnosis?

Physiological jaundice 10%

Sepsis 2%

✓ Biliary atresia 71%

x Breastmilk jaundice 10%

G6DP deficiency 7%

ANSWER
Biliary atresia is characterised by obliteration or discontinuity of the extrahepatic biliary system, resulting in obstruction to bile flow. The disorder
represents the most common surgically treatable cause of cholestasis encountered during the newborn period. The clinical presentation is
usually with jaundice, dark urine and pale stools.
 Neonatal Emergencies  QUESTION 16

A 1 week old boy is brought to the Emergency Department as his mother is concerned he has turned yellow. On
examination you note jaundice of the skin and sclera. Which of the following features is most concerning in a patient
with neonatal jaundice?

Jaundice in neonates who are exclusively breastfed 6%

Jaundice first appearing at day 3 10%

✓ Jaundice first appearing within 24 hours 73%

x Jaundice associated with yellow sclera 5%

Jaundice in babies who were born after 41 weeks 6%

ANSWER
Jaundice presenting in the first 24 hours of life is more likely to have a serious underlying cause such as infection, haemolytic disease or
metabolic disorder. Any baby presenting with jaundice in the first 24 hours of life should therefore be seen urgently for assessment in hospital.
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Neonatal Emergencies  QUESTION 17 >

A 36 year old woman presents to the Emergency Department in active labour. Shortly after her arrival
in the ED a baby boy is delivered. His observations are recorded as:
Completely pink
Heart rate: 90 beats per minute
Grimaces when stimulated
Floppy
Slow respiratory effort
What is his APGAR score?

✓ 5 46%

x 6 31%

7 14%

8 4%

9 5%

ANSWER

Sign/Score 0 1 2
Appearance (colour) Pale blue Body pink, extremities blue Completely pink
Pulse rate Absent < 100 > 100
Grimace (reflex irritability) No response to stimulation Grimaces when stimulated Cries when stimulated
Activity (muscle tone) Limp Some flexion of extremities Active
Respiratory effort Absent Slow/irregular Strong cry

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 Neonatal Emergencies  QUESTION 18

A one week old infant is brought to the Emergency Department. She is pyrexic, floppy and unresponsive with a
bulging fontanelle. Empirical antibiotics are started and a lumbar puncture is performed which demonstrates Gram-
negative rods. What is the most likely causative pathogen?

Staphylococcus aureus 2%

✓ Escherichia coli 49%

Group B streptococcus 16%

x Neisseria meningitidis 26%

Haemophilus influenzae 8%

ANSWER
In neonates (children younger than 28 days), the most common causative organisms are Streptococcus agalactiae (Group B streptococcus) -
Gram positive cocci, Escherichia coli - Gram negative rods, Streptococcus pneumoniae - Gram positive cocci and Listeria monocytogenes - Gram
positive rods.
 Neonatal Emergencies  QUESTION 19

A 5 day old girl is brought to the Emergency Department by her mother. She is concerned as over the previous 24
hours her feeding has reduced, she is making fewer wet nappies and she has a temperature of 38.6°C. On
examination you note an increased central capillary refill time and a pale appearance. You suspect neonatal sepsis.
What is the most appropriate treatment for this baby?

Ceftriaxone 17%

Co-amoxiclav 2%

Piperacillin with tazobactam 6%

✓ Benzylpenicillin and gentamicin 50%

Amoxicillin and cefotaxime 25%

ANSWER

If a baby needs antibiotic treatment it should be given as soon as possible and always within 1 hour of the decision to treat.
Use intravenous benzylpenicillin with gentamicin as the first-choice antibiotic regimen for empirical treatment of suspected infection
unless microbiological surveillance data reveal local bacterial resistance patterns indicating a different antibiotic.
 Neonatal Emergencies  QUESTION 20

A 16 year old girl self presents to the Emergency Department in active labour. She has been concealing the pregnancy from her parents.
Shortly after arrival a baby boy is delivered. You have dried, warmed and stimulated the baby and placed him in a neutral position. The
baby is not breathing. What is the next management step?

Start chest compressions 3%

✓ Give five inflation breaths 87%

Give IV adrenaline 2%

x Intubate and provide positive-pressure ventilation 3%

Apply 100% oxygen 5%

ANSWER

Consider the need for help; if needed, ask for help immediately.
Dry the baby
Maintain normal temperature
Start the clock or note the time
Assess tone, breathing and heart rate
If gasping or not breathing:
Open the airway
Give five inflation breaths
Consider SpO2 +/- ECG monitoring
 Neonatal Emergencies  QUESTION 21

A 1 week old girl is brought to the Emergency Department by her mother. She is concerned as over the previous 24 hours
her feeding has reduced, she is making fewer wet nappies and she has a temperature of 38.6°C. On examination you note
an increased central capillary refill time and a pale appearance. You suspect neonatal sepsis. What is the most likely
causative organism?

Staphylococcus aureus 15%

Neisseria meningitidis 7%

✓ Group B Streptococcus 65%

Listeria monocytogenes 12%

Staphylococcus epidermidis 2%

ANSWER
The most frequent cause of severe neonatal infection is Group B Streptococcus (GBS).

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