MRCPCH GUIDE NEONATE

Medical treatment of seizures

Seizure Type Generalised Partial
Symptomatic
Partial- Benign Infantile spasms
1
st
Line Sodium Valproate Carbamazepine

Nothing

Vigabatrin

2
nd
Line Lamotrogine/
carbamazepine
Lamotrogine

Carbemezepine

ACTH

3
rd
Line Gabapentin/
Topiramate/
Clonazepam
Topiramate

4
th
Line Phenytoin



The airways begin as an outpouching from the primitive gut at 24 days and by 26 days two
primary branches, which will go to form the major bronchi, can be discerned. For the next 3
months growth consists of branching of the endodermal tube into the surrounding
mesenchyme. By 10 weeks cartilage is deposited in the bronchi and by 16 weeks formation of
new bronchi is almost complete. The terminal air sacs or alveoli appear as outpouchings of the
bronchioles after 28 weeks and increase in number to form multiple pouches of a common
chamber called the alveolar duct. After birth alveolar stability is dependent upon the release
of pulmonary surfactant into the lumen. Synthesis and release of surfactant rely more on
humoral control mechanisms than mechanical factors. Alveolar type II cells, which synthesize
surfactant, have microvilli on the luminal surface and contain lamellar bodies. The lamellar
bodies (storage sites for surfactant) are first recognized at about 22 weeks. The terminal air
sacs are shallow and wide mouthed in the newborn baby; several months later they assume a
cup shape. Growth of the lung occurs by increasing the number of bronchiolar divisions,
alveoli, alveolar diameters and surface area for gas exchange. Alveoli may continue to form as
long as body length increases.
Hydrops Fetalis
The importance of infection with B19V is increasingly recognised. Use of diagnostic tests has
demonstrated that perhaps 20% of fetal hydrops is associated with this maternal/fetal
infection. Other infectious causes include Cytomegalovirus (CMV), Syphilis, herpes simplex,
Toxoplasmosis, hepatitis B, Adenovirus, Ureaplasma urealyticum, Coxsackievirus type B,
Listeria monocytogenes.
The pH of a healthy newborn is between 7.35 and 7.4. The systolic blood pressure at term is
normally 60mmHg rising to 90mmHg by 1 year. The survival of infants at 23 weeks is in the
order of 30% and rises to around 85% by 28 weeks. The average OFC at term is about 35cm
while the PNMR is 7-8/1000 of all births (i.e. live births & still births).
ROP is a disease of premature infants. All babies less than 1500 g birth weight or younger than
32 weeks' GA at birt h are at risk of developing ROP. However, higher oxygen saturation levels
were not found to worsen the disease in prethreshold babies. Laser surgery (xenon, argon,
diode) has been shown to be as effective as cryotherapy for ROP and is used in more advanced
cases. Complications include: Loss of vision, amblyopia due to high refractive errors,
Strabismus, Glaucoma, Retinal detachment.
IUGR has a prevalence of 10% among all pregnancies. However, the figure varies in different
patient populations, with rates of 3-5% among healthy mothers, and rates of 25% or higher in
some high risk groups, such as, hypertensive mothers. The cause is often not known.
Growth-restricted pregnancies are often complicated by a high rate of antepartum and
intrapartum fetal distress and the need for caesarean delivery. Infants born who are small for
their gestational dates are predisposed to higher rates of low APGAR scores, low cord pH,
intraventricular haemorrhage, necrotising enterocolitis, hypoglycaemia, hypocalcaemia, and
polycythaemia.
The sonographic criteria for IUGR include (1) an elevated ratio of femoral length to abdominal
circumference (AC), (2) an elevated ratio of head circumference (HC) to AC, and (3)
unexplained oligohydramnios .
In most cases of IUGR, especially those due to primary placental insufficiency (the most
common cause), the fetal abdomen is small, while the head and extremities are normal or near
normal. This finding is known as the head-sparing effect. In cases of severe, early-onset IUGR
(those due to chromosomal anomalies), the fetus tends to be more symmetrically small.

Many syndromes representing problems in the morphogenesis of branchial arches [5], [8] have
been reported including Goldenhaar syndrome, Pierre Robin and Treacher Collins syndrome.
Ectopic thyroid tissue may be present anywhere along the path of descent of the thyroid gland.
A pilonidal sinus is in the natal cleft.

In the first week of life in utero (1/40), the embryo derives its nutrients and discards its waste
by a simple process of diffusion. Development of the uteroplacental circulation commences
at 9 days and is fully established within the third week after fertilisation (3/40). The
cytotrophoblast proliferates, and processes form the primary stem villi. Further differentiation
of the mesoderm forms the blood vessels, which subsequently connect with the vessels
forming in the embryo. These differentiated structures are called the tertiary stem villi. Gases,
nutrients and wastes diffuse between maternal and fetal blood between four established
layers: (1) the endothelium of the villus capillaries; (2) the villus connective tissue; (3) a layer
of cytotrophoblast; and (4) a layer of syncytiotrophoblast. The placenta contains 150 ml of
maternal blood and is replaced 34 times per minute. Carbon dioxide, urea and uric acid pass
from the fetal to the maternal blood as waste.
Trophoblastic lacunae develop within the syncytiotrophoblast. Maternal capillaries within
this area expand to form maternal sinusoids. Extra-embryonic mesoderm grows and extends
into the primary stem villi to become secondary villi. The placenta produces steroid
hormones and prostaglandins.


The pharyngeal pouches consist of bars of mesenchymal tissue separated from each other by
pharyngeal pouches and clefts. The endoderm of the pouches gives rise to, in order, the
structures indicated in the table below.
Pouch Structure formed
1st pouch Pharyngotympanic cavity, Auditory tube, Eustachian tube
2nd pouch Tongue, Palatine tonsils
3rd pouch Thymus, Inferior parathyroid gland
4th pouch Superior parathyroid gland (C cells)
4th5th pouch Ultimobranchial bodies (parafollicular cells)
The thyroid gland originates from epithelial proliferation in the floor of the primitive pharynx
and not from the larynx or branchial arches. It is connected by the thyroglossal duct to the
foramen caecum at the junction of the anterior two-thirds and posterior third of the tongue.
Ectopic thyroid tissue occasionally causes cysts along the path of the duct. The thyroid
migrates to its final position in front of the tracheal rings. The parafollicular (C) cells come
from the ultimobranchial body, a derivative of the 4th pharyngeal pouch.

Impaired fetal lung development is seen in Potter syndrome, Jeune syndrome and dystrophia
myotonica. It is not found in the infants of insulin-dependent diabetic mothers or in
Duchenne muscular dystrophy. Impaired fetal lung development is not found in bronchiolitis,
facioscapulohumeral dystrophy, Pickwickian syndrome or Kartagener syndrome.



Cocaine, carbimazole and warfarin readily cross the placenta and affect the fetus.

FAS was first reported as a syndrome in 1973 and is now thought to be one of the major causes
of mental retardation, having an incidence of 0.23 per 1000 live births. It has been estimated
that between 10 and 20% of mild mental retardation cases are caused by maternal alcohol use.
Severity and timing of alcohol consumption, bingeing, polydrug use (including smoking) during
pregnancy, genetic variation and low socioeconomic status are all aetiological factors. Alcohol
inhibits N-methyl-d-aspartate (NMDA) receptors, which mediate the postsynaptic excitatory
effects of glutamate, and this is thought to have an effect on cell proliferation.

Affected newborns are often irritable, hypotonic, experience severe tremors and show other
signs of alcohol withdrawal. The cardinal signs are facial features, growth deficit and central
nervous system impairment. Facial features include epicanthic folds, microcephaly, short -
palpebral fissure, underdeveloped philtrum and a thin upper lip. There are often associated
behavioural difficulties including hyperactivity and sleep disturbance. Optic nerve hypoplasia
with poor visual acuity, hearing loss and receptive and expressive language deficits can also be
seen. Cardiac and renal abnormalities include atrial and ventricular septal defects, renal
hypoplasia and bladder diverticula.

Prognosis depends on grade of bleed: grades 1 and 2 have a good prognosis with no long-
term effects. In grade 3 there may be possible impairment on the contralateral side, depending
on the degree of progression of dilatation, and in grade 4 there is likely to be motor
impairment on contralateral side.