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
urination patterns in first few days of life and color
3-4 times a day by the third day, and at least 6-8 times a day by the sixth day of life. Urine should be pale yellow.
major vs minor RF for severe hyperbil
major - w/i first 24h, abo incopatbility, 35-36weeker, sibling needed tx, bruising, east asian, or tBili in high risk zone
minor - tBIli in high intermediate zone, 37-38weeker, jaundice before discharge, sib w jaundice, male, mom age >25yo, macrocosmic infant of DM mom
decreased risk for severe hyperbil
TSB or TcB level in the low-risk zone Gestational age 41 week Exclusive bottle feeding Black race Discharge from hospital after 72 hours
tlyenol and codine w/ Bfeeding
not compatabilie
if breast engagement,
use cold(between) and warm(befe) compresses, have baby nurse often, manual or mech expression of areola
vitamins for exclusively BF infants
vit D in first 6 mos, but also need sunlight! and iron at 6 mos
fluoride rules
all babies - BF Or bottle- should receive fluoride (B) supplements after the age of 6 months if the water supply lacks fluoride (< 0.3 ppm).
Note that most bottled and filtered water has low fluoride levels.
initial weight loss n babies
reastfed infants may lose up to 7%-10% of their birth weight during the first 4 to 5 days of life, and typically regain birth weight by at least 2 weeks of age.
progression of jaundice in babies on body
cephalo–>caudal
face = face at a bilirubin level of approximately 4-5 mg/dL (68-86 μmol/L).
knees = estimate the bilirubin level to be in the 10-15 mg/dL (171-257 μmol/L) range when jaundice is visible below the knees, but the experienced pediatrician also knows that this is only an estimate of serum bilirubin levels.
caput succadeum vs cephalohematoma
cephalohem = subperiosteal hemorrhage that is localized to the cranial bone that was traumatized during delivery.
The swelling does not extend across a suture line.
As the blood is reabsorbed from the cephalohematoma it will contribute to hyperbilirubinemia.
succ = edematous swelling over the presenting portion of the scalp of an infant.
It overlies the periosteum and the swelling crosses suture lines.
The swelling consists of serum and would not cause hyperbilirubinemia
DDH RF incudng gender . position at birth, fh, race
Girls Infants born via breech presentations Caucasians Native Americans or When there is a family history of DDH.
imaging breech females need, why and when
Imaging of the hips is recommended for all female infants born via breech delivery either with ultrasound at 4-6 weeks or a hip and pelvis radiograph at 4 months; such imaging is optional for male infants.
when to order hgb and cbc in jaundice eval
If there is a suspicion of hemolytic disease or anemia (e.g., jaundice in the first day of life or TSB >14 in the first 48 hours).
when to order TSB
If jaundice is noted in the first 24 hours of life or with significant jaundice.
when to order direct bili or urine dipstick bili
Infant has dark urine or light stools.
Persistent jaundice (> 3 weeks).
Infant is ill (there will be an increased direct bilirubin with sepsis/congenital infection).
galactosemia eval
could look at urine for reducing substances
neonatal screening time
Optimal time for testing is ≥ 24 hours after birth.
A specimen obtained before 24 hours of age may miss PKU and other disorders with metabolite accumulation.
If the first specimen was obtained prior to 24 hours, a second specimen should be obtained in the next one to two weeks.
do hemoglobinopathies cause newborn jaundice
no - sickle cell etc can but this wouldn’t manifest til ~6 months
tx breastmilk jaundice
The AAP encourages continued and frequent breastfeeding in healthy term newborns with jaundice. Many pediatricians might consider a temporary interruption of breastfeeding (C) when the bilirubin level is somewhere in the 16-25 mg/dL (274-428 μmol/L) range.
If this management is chosen, the interruption of breastfeeding is usually limited to a period of 24-48 hours, and then breastfeeding can be resumed.
While this may shorten the duration of jaundice, it provides no long-term benefit to the infant and may prove detrimental if the mother does not resume breastfeeding.
increasing dir bili could suggest
bil atresai, a1at def
when does CN appear
in first days of life
