CLIPP 8

Question 1

most of bilirubin in newborn comes from

Answer 1

physiologic breakdown of rbc

Question 2

pathway of bilirubin

Answer 2

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

Question 3

kernicterus

Answer 3

= 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

Question 4

anemia, shock, acidosis and high T bili

Answer 4

RH incompatbility–>kernicteurs due to high hemoylsis

Question 5

tx to avoid kernicterus

Answer 5

phototherapy to tx unconjug bili - look at FA for specific

Question 6

ABO incompatability vs mismatch vs set up

Answer 6

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..?

Question 7

if mom and baby are both + blood type even if diff letters,

Answer 7

there is no RH incompatability

Question 8

is O+ A+ ABO incompatibility ?

Answer 8

need coombs to know

if O+A+ with +coombs, then yes incompatibility. if -coombs, then set up

Question 9

breastfeeding is higher or lower jaundice risk

greek/mediterr is higher or lower jaundice risk

Answer 9

both are higher jaundice

Question 10

physiologic jaundice

Answer 10

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

Question 11

factors that can cause physiol jaundice

Answer 11

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).

Question 12

breastfeeding jaundice vs breast milk jaundice

Answer 12

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

Question 13

most common forms of antibody positive hemoylsis are____ (4) ___ and cause __

Answer 13

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

Question 14

categories of other things that can cause jaundice besides hemolytisis

Answer 14

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

Question 15

colostrum

Answer 15

made in the initial days of feeding, has concentrated amount of nutrients

Question 16

if can’t breastfeed, should use

Answer 16

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.

Question 17

lipids iin breasktmilk

Answer 17

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.

Question 18

protein - in formula, unmodified cows milk human milk

Answer 18

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.

Question 19

What condition causes jaundice in individuals of Greek (or other Mediterranean, Middle Eastern, African, or Asian) origin?

Answer 19

g6pd dfeiciency - XL recessie(i.e. girls need 2 x’s w defect, boys need 1), can lead to anemia and jaundice

Question 20

when should meconium stop appearing in stool and progression of stool color

Answer 20

day 3 of life, should become yellow. stool in breastfed babies should not have much smell

Question 21

concerning stool

Answer 21

if stool loses color and becomes grey/acholic - concern for biliary atresia

Question 22

biliary atresa sx

Answer 22

healthy-appearing infant who develops jaundice, dark urine, and acholic (pale) stools between 3 and 6 weeks of age

Question 23

how to eval baby w/ jaundice after 2 weeks of age

Answer 23

frac. bili (dir and indir)

Question 24

kasai procedure

Answer 24

anastomosis of the intrahepatic bile ducts to a loop of intestine to allow bile to drain directly into the intestine

Question 25

urination patterns in first few days of life and color

Answer 25

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.

Question 26

major vs minor RF for severe hyperbil

Answer 26

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

Question 27

decreased risk for severe hyperbil

Answer 27

TSB or TcB level in the low-risk zone
Gestational age 41 week
Exclusive bottle feeding
Black race
Discharge from hospital after 72 hours

Question 28

tlyenol and codine w/ Bfeeding

Answer 28

not compatabilie

Question 29

if breast engagement,

Answer 29

use cold(between) and warm(befe) compresses, have baby nurse often, manual or mech expression of areola

Question 30

vitamins for exclusively BF infants

Answer 30

vit D in first 6 mos, but also need sunlight! and iron at 6 mos

Question 31

fluoride rules

Answer 31

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.

Question 32

initial weight loss n babies

Answer 32

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.

Question 33

progression of jaundice in babies on body

Answer 33

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.

Question 34

caput succadeum vs cephalohematoma

Answer 34

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

Question 35

DDH RF incudng gender . position at birth, fh, race

Answer 35

Girls
Infants born via breech presentations
Caucasians
Native Americans or
When there is a family history of DDH.

Question 36

imaging breech females need, why and when

Answer 36

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.

Question 37

when to order hgb and cbc in jaundice eval

Answer 37

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).

Question 38

when to order TSB

Answer 38

If jaundice is noted in the first 24 hours of life or with significant jaundice.

Question 39

when to order direct bili or urine dipstick bili

Answer 39

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).

Question 40

galactosemia eval

Answer 40

could look at urine for reducing substances

Question 41

neonatal screening time

Answer 41

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.

Question 42

do hemoglobinopathies cause newborn jaundice

Answer 42

no - sickle cell etc can but this wouldn’t manifest til ~6 months

Question 43

tx breastmilk jaundice

Answer 43

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.

Question 44

increasing dir bili could suggest

Answer 44

bil atresai, a1at def

Question 45

when does CN appear

Answer 45

in first days of life