1: Neonatology - Jaundice Flashcards by Grace Poole

What causes jaundice

Hyperbillirubinaemia

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What % of neonates will experience some form of jaundice

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What time-frame does physiological neonatal jaundice occur

> 24h.

Usually 2-14d.

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What are 4 causes of physiological jaundice

Shorter RBC lifespan
Hepatic Immaturity
Absence Gut Flora
Exclusive Breast Feeding

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Explain hepatic immaturity

Unable to conjugate bilirubin for excretion leading to accumulation

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Why may absence of gut flora cause physiological jaundice

Unable to eliminate bile pigment

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Why may breast feeding cause jaundice

Feeding difficulties can lead to dehydration, relatively increasing bilirubin.

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What does jaundice in first -24h always indicate

Pathological cause

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What are four possible causes of jaundice within the first 24 hours

Rhesus haemolytic disease
ABO haemolytic disease
Hereditary spherocytosis
G6PD deficiency

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What test can be used for rhesus haemolytic disease

Direct Coombs Test

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What test can be used to detect hereditary spherocytosis

Fragility Test

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Define prolonged jaundice in term infant

> 14d

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Define prolonged jaundice in pre-term infant

> 21d

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What are 5 causes of prolonged jaundice

Biliary atresia
Hypothyroidism
Sepsis - TORCH
Cystic Fibrosis
Galactosaemia

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What causes unconjugated hyperbillirubinaemia in first 24h

Haemolytic disease:

Rhesus
ABO
G6P
Hereditary Spherocytosis

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What causes conjugated hyperbillirubinaemia in first 24h

TORCH Infection

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What causes uncognjugated hyperbillirubinaemia in 2-14d

Physiological Jaundice

- Breast Feeding Jaundice

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What causes unconjugated hyperbillirubinaemia >14d

Breast Milk Jaundice
Congenital Hypothyroid
TORCH

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How will conjugated hyperbillirubinaemia present

Pale stools, Dark Urine

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What causes conjugated hyperbillrubinaemia >14d

Biliary atresia

- Neonatal hepatitis

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What are 5 risk factors for pathological jaundice

Low birth weight
Pre-mature
Previous sibling affected
Birth trauma
Known Rhesus or ABO incompatibility

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How will conjugated hyperbilirubinaemia present

Pale Stools

Dark Urine

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What causes conjugated hyperbillirubinaemia

Biliary Atresia

Neonatal hepatitis

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What does hepatomegaly and splenomegaly associated with jaundice indicate

It is not associated with physiological jaundice - therefore pathological cause

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What is breast feeding jaundice

Infant breast feeds it can lead to dehydration. This can reduce clearance of bilirubin

When does breast feeding jaundice occur

Day 2-14

What is breast milk jaundice

Breast Milk contains B-glucoronidase. It reduces conjugation and increases absorption of billirubin causing persistent physiological jaundice

When does breast milk jaundice occur

>14d

When should all babies be checked for jaundice

Newborn Infant Physical Exam - in 72h. Or 48h if risk factors.

What is first line investigation for jaundice babies

Measure Bilirubin

When should serum bilirubin measurement be used

If neonate less than 24h. Or delivered less than 35W gestation.

When should transcutaneous billrubinometer be used

If neonate more than 24h. Or, delivered more than 35W

If a transcutaneous bilirubinometer shows a bilirubin of more than 250 what should be done

Serum bilirubin

If a jaundice baby is less than 24h, how often should serum bilirubin be measured

Measure within 2h. Then monitor every 6h.

If a jaundice baby is more than 24h, how often should serum bilirubin be measured

6h.

What tests may be used to identify cause of jaundice in first 24-hours

- Coombs Test | - Blood group

If clinically indicated what other tests may be performed

FBC Blood Film G6PD enzyme levels Blood culture

Which gender is G6PD more likely in

Males

If a conjugated billirubinaemia what may be performed and why

US bile duct and GB due to risk of biliary atresia

If bile duct dilated on US what may it indicated

Choledochal cyst

If bile duct is not dilated dilated on US what may be performed

TIBDA scan

What defines term

37-40W delivery

What defines prolonged jaundice in a term baby

>14d

What defines prolonged jaundice in a pre-term baby

>21d

What is a prolonged jaundice screen

- Pale Stools/ Dark Urine - Bilirubin - FBC - Blood Group - Urine culture - TFTs

What does bilirubin level determine

It is plotted on a graph against time to determine if phototherapy or exchange transfusion is required

What is phototherapy and how does it work

Phototherapy uses UV light to covert bilirubin to soluble products (eg. lumirubin) that can be excreted without conjugation

What are side effects of phototherapy for jaundice

- Eye damage | - Seperation from mother

If jaundice due to ABO or Rhesus incompatibility - what is given alongside phototherapy

IVIG

What is exchange transfusion

Donor warmed blood is given to foetus by umbilical vein and removed from umbilical artery. Aim is to remove high bilirubin

If biliary atresia is suspected how is jaundice managed

Urgent surgical review

What worrying syndrome may hyperbillirubinaemia cause

Acute bilirubin encephalopathy

When does acute bilirubin encephalopathy occur

First few days of life

How will acute bilirubin encephalopathy present

- Lethargy - Hypotonia - Irritable - Poor Feeding - Shrill Cry

What is kernicterus

Progression from acute bilirubin encephalopathy

What are three RF for kernicterus

- Rapidly rising Increase in bilirubin >8.5 - Serum bilirubin >340 - Clinical features bilirubin encephalopathy

How will kernicterus present

- Vertical Gaze Palsy - Cerebral paresis - Hearing Impairment - Athetosis - Intellectual disability - Dental enamel hypoplasia

Why would jaundice due to biliary atresia not cause kernicterus

As only unconjguated hyperbillirubinaemia can cross the BBB to cause kernicterus. Conjugated is water-soluble and therefore cannot cross BBB

What is biliary atresia

Obliteration or discontinuity of biliary tract

In which gender is biliary atresia more common

Females

How does biliary atresia present clinically

- Prolonged jaundice - Dark urine - Pale stools

What is a sign of biliary atresia

Hepatosplenomegaly

Explain pathophysiology of biliary atresia

Obliteration of biliary tree, leads to cholestasis increases pressure causing portal HTN

What investigations are ordered in biliary atresia

LFTs USS TBIDA scan

What may be seen on LFTs in biliary atresia

High conjugated bilirubin Normal total bilirubin Abnormal liver transaminases

What may be seen on USS in biliary atresia

Non-patent biliary tree

What may be seen on TBIDA scan in biliary atresia

Non-patent biliary tree

What is management of biliary atresia

Hepatoportenterostomy = anastamosis between liver and small intestine