Case 8 - 6 day old with jaundice

Question 1

Which one has potential serious consequences: unconjugated or conjugated hyperbilirubinemia?

Answer 1

unconjugated because it can cross the BBB and cause kernicterus

Question 2

What areas of the brain are affected by kernicterus?

Answer 2

basal ganglia and cranial nerve nuclei

Question 3

What are some of the signs and symptoms of kernicterus?

Answer 3

babies that lose the suck reflex, become lethargic, develop hyperirritability and seizures

can ultimately die

Question 4

Infants who survive kernicterus can develop what?

Answer 4

opisthotonus
rigidity
oculomotor paralysis
tremors
hearing loss
ataxia

Question 5

What was the most common cause of kernicterus in the past?

Answer 5

hemolysis and subsequent unconjugated hyperbilirubinemia that was caused by Rh incompatibility before rhogam

Question 6

75% of the bilirubin produced in health newborns comes from where?

Answer 6

physiological breakdown or RBCs

Question 7

What enzyme conjugates bilirubine iwht glucuronide?

Answer 7

uridine diphosphate glucuronyl transferase (UDPGT)

Question 8

Why does the conjugated bile in a baby’s GI tract get hydrolyzed back to its unconjugated form and then reabsorbed into the blood stream to cause problems?

Answer 8

babies lack the GI flora to metabolize bile, which allows the glucuronidase present in meconium to hydrolyze it back tot he unconjugated form

Question 9

Jaundice that is caused by this enterohepatic circulation issue is caused what?

Answer 9

physiologic jaundice

Question 10

Physiologic jaundice is usually with a total bili less than ___ in full-term infants who are otherwise healthy. It’s benign and self-limited. When does it present?

Answer 10

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presents by the second or third day of life, peakin gon days 3 or 4

Question 11

What is breastfeeding jaundice?

Answer 11

it’s when there’s a relatively low milk supply (so happens early in the first week of life), resulting in limited enteral intake

the low intake decreases GI motility, which promotes retention of the meconium that has the glucuronidase to deconjugate the bili

(so difficult to distinguish from physiologic jaundice and probably overlaps)

Question 12

What is breast-milk jaundice?

Answer 12

the glucuronidase present in breast milk deconjugates the bilirubin in the GI tract and is reabsorbed

Question 13

When does breast-milk jaundice present?

Answer 13

Days 4-7

Question 14

What lab should you run to test for hemolysis as a cause of jaundice?

Answer 14

Coombs test

Question 15

What are some non-hemolytic RBC breakdown causes that can lead to jaundice?

Answer 15

extensive bruising from birth trauma
large cephalohematoma or other hemorrhage
polycythemia at birth
swallowed blood (from mom) during delivery

Question 16

Which ethnicities have more jaundice?

Answer 16

asians more so than caucasians more so than blacks

Question 17

What is a typical breastfeeding pattern for a new baby?

Answer 17

8-12 times/day; about 10-15 minutes at each breast

Question 18

True or false: infants younger than 12 months should not be fed unmodified cow’s milk.

Answer 18

true

Question 19

How often should a newborn pee?

Answer 19

3-4 times during days 3-6

6-8 times after day 6

Question 20

How many stools do most newborns have in a day?

Answer 20

3-4

Question 21

Stool that gradually loses color and becomes “acholic” could be a sign of what? (especially when accompanied by jaundice and dark urine)

Answer 21

biliary atresia

Question 22

What is the treatment for biliary atresia?

Answer 22

if diagnosed early, can be treated surgically with the Kasai procedure (anastomosis of the intrahepatic bile ducts to a loop of intestine to allow bile to drain direcctly into the intestine)

Question 23

When should you get imaging (and what type) of the hip in all female infants born via breech delivery?

Answer 23

ultrasound at 4-6 weeks or hip/pelvis radiograph at 4 months

Question 24

Hypothyroidism that is not detected on the newborn screen can cause what signs and symptoms?

Answer 24

prolonged jaundice
lethargy
large fontanelles
macroglossia
umbilical hernia
constipation
abdominal distention
severe developmental delay

Question 25

What is the optimal time for the newborn screen to be collected?

Answer 25

over 24 hrs after birth because if you get it before, you may miss PKU and other disorders with metabolite accumulation

Question 26

What is a normal amount of weight loss during a newborn’s firt 4-5 days of life?

Answer 26

7-10%

Question 27

WHere in the body is jaundice first noticed (and at what level)?

Answer 27

face at 4-5mg/dL

Question 28

What labs should you get with hyperbilirubinemia in an infant?

Answer 28

ABO and Rh type and cross for mom and DAT with baby's cord blood
G6PD screen
total serum bili
direct and indirect
urine bili
CBC, retic, smear
newborn screen

Question 29

True or false: if a baby has breast milk jaundice, they need to stop breastfeeding.

Answer 29

false - it’s not necessary in almost all cases, although temporary cessation may be helpful

Question 30

How old should a baby be before you start iron supplementation?

Answer 30

6 mo