CLIPP 8 Flashcards
most of bilirubin in newborn comes from
physiologic breakdown of rbc
pathway of bilirubin
breakdown of rbc leads to ucb that is insoluble–>conj by udpgt i.e. glucuronyl transferase in liver and this is water soluble and excr into intestines to mix w/ bile and in adults, bile is metabolized into robin which goes into poop. newborns lack the intestinal flora to metabolize bile so beta glucuronidase in mecronium converts the cb into ucb and its reabsorbed
kernicterus
= high levels of unconjugated bili
- staining of BG and CN nuclei by UNCONJUG bili–>lose suck reflex, lethargy, irritability, seizures, die
- if survive, get opthithonos (rigidity and severe posturing), ataxia, paralysis, hearing loss
anemia, shock, acidosis and high T bili
RH incompatbility–>kernicteurs due to high hemoylsis
tx to avoid kernicterus
phototherapy to tx unconjug bili - look at FA for specific
ABO incompatability vs mismatch vs set up
i: mom specifically has O, baby has A or B, and +coombs direct. jaundice typically within first 24h and coombs may be + or weakly + thus actual ABO hemolytic dz is rare end of spectrum as only 1/5 A or B infants get clinically sig jaundice bc babies have fewer reactive A or B sites (but if tx baby w/ jaundice, tx more aggressively if you know they have hemolytic dz)
m: happens in 20% pregnancies
s: if coombs negative
-jaundice w/ abo hemoylsis is something that appears within first day or so of life..?
if mom and baby are both + blood type even if diff letters,
there is no RH incompatability
is O+ A+ ABO incompatibility ?
need coombs to know
if O+A+ with +coombs, then yes incompatibility. if -coombs, then set up
breastfeeding is higher or lower jaundice risk
greek/mediterr is higher or lower jaundice risk
both are higher jaundice
physiologic jaundice
total bili <15, in otherwise healthy FT infants wo other causes for bili and often noticed on 2nd or 3rd day of life, , w/ bili peaking on day 3 or 4
factors that can cause physiol jaundice
Increased bilirubin production (from the breakdown of the short-lived fetal red cells) Relative deficiency of hepatocyte proteins and UDPGT Lack of intestinal flora to metabolize bile High levels of β-glucuronidase in meconium Minimal oral (enteral) intake in the first 2-4 days of life, resulting in slow excretion of meconium (especially common with breastfed infants).
breastfeeding jaundice vs breast milk jaundice
breastfeeding jaundice aka lack of breastmilk jaundice aka breastfeeding associated jaundice occurs in first week of life as milk supply is low so there is limited parenteral intake so less GI motility and this leads to retention of meconium and there is b-glucuronidase in meconium which then deconjug the bili–>incr UCB which is abs via enterohepatic circulation. this can be hard to distinguish from physiologic jaundice
VS
breast milk jaundice peaks around 10-14d but starts around d4-7, and not due to low breast milk. theory is b-glucuronidase in breast milk deconjug the GI tract bilirubin. can petsit up to 12 weeks but rarely reaches concerning levels
most common forms of antibody positive hemoylsis are____ (4) ___ and cause __
Rh incompatibility (mother is Rh-negative and baby is Rh-positive) ABO incompatibility (mother is type O and baby is type A or B) Incompatibilities with minor blood group antigens (much less common) Antibody-negative hemolysis occurs in infants who have red cell membrane defects (e.g., spherocytosis) or red cell enzyme defects (glucose-6-phosphate dehydrogenase or pyruvate kinase deficiency).
–>direct antibody test( DAT) + coombs
categories of other things that can cause jaundice besides hemolytisis
NON hemolytic rbc breakdown = bruising from birth trauma, polycytehmia, cephalohematoama, swallowed blood in delivery
metabolic issues = galacetosemia, hypothy CN syndrome where UDPGT is totally absent (all (seen on newborn screen)
ethnicity = more common in asians than caucasins, less common in blacks
also = prematurity , bowel obst, birth at high alt
colostrum
made in the initial days of feeding, has concentrated amount of nutrients
if can’t breastfeed, should use
formula made from cow’s milk or soy protein isolate, with assurance that the major nutrients will be provided by either.
Infants younger than 12 months should not be fed unmodified cow’s milk.
lipids iin breasktmilk
Approximately 50% of calories in human milk come from lipids.
The lipid concentration in breast milk increases as the nursing episode proceeds; therefore, it is important that an infant empty the breast before going to the next breast.
protein - in formula, unmodified cows milk human milk
Human milk contains a combination of whey proteins (70%) and casein (30%).
Formulas provide nutrition comparable for all major nutrients to human milk, although they contain slightly more protein than human milk.
The casein:whey ratio of cow-milk-based formulas varies.
Unmodified cow milk contains approximately three times the protein content of human milk and has ~80% casein and 20% whey proteins.
As mentioned above, it is not suitable for young infants.
What condition causes jaundice in individuals of Greek (or other Mediterranean, Middle Eastern, African, or Asian) origin?
g6pd dfeiciency - XL recessie(i.e. girls need 2 x’s w defect, boys need 1), can lead to anemia and jaundice
when should meconium stop appearing in stool and progression of stool color
day 3 of life, should become yellow. stool in breastfed babies should not have much smell
concerning stool
if stool loses color and becomes grey/acholic - concern for biliary atresia
biliary atresa sx
healthy-appearing infant who develops jaundice, dark urine, and acholic (pale) stools between 3 and 6 weeks of age
how to eval baby w/ jaundice after 2 weeks of age
frac. bili (dir and indir)
kasai procedure
anastomosis of the intrahepatic bile ducts to a loop of intestine to allow bile to drain directly into the intestine
