CLIPP 8 - jaundice

Question 1

Newborn bilirubin physiology

Answer 1

Hgb -> unconjugated bilirubin -> albumin -> liver -> conjugated with glucuronide (UDGPT) -> bile excretion -> B-glucuronidase unconjugates -> reabsoprtion

Question 2

kernicterus (7actue features, 6 long term features, and 8 risk factors)

Answer 2

• acute: poor suck, high-pitched cry, hypotonia, lethargy, seizures, extensor hypertonia, opisthonus
• kernicterus: tone/reflex abnormalities, choreoathetosis, tremor, oculomotor paralysis, sensorineural hearing loss, cognitive impairment
• risk factors: serum bilirubin >20-25, hemolysis, asphyxia, lethargy, temperature instability, sepsis, acidosis, albumin <3

Question 3

Newborn jaundice causes (7)

Answer 3

• physiologic jaundice (bilirubin <15, full term, healthy infants)
• breastfeeding jaundice (limited enteral intake, decreased GI motility)
• breast milk jaundice (B-glucuronidase present in breast milk)
• hemolysis (antibody-positive, RBC membrane defects, RBC enzyme defects)
• non-hemolytic RBC breakdown (birth trauma, polycythemia, swallowed blood)
• metabolic errors (crigler-najjar, gilbert syndrome, galactosemia, hypothyroidism)
• neonatal sepsis
• congenital infection

Question 4

Infant benefits of breastfeeding (4)

Answer 4

• maternal-infant bonding
• infection prevention
• reduced SIDS rate
• reduced rate of allergic reactions

Question 5

Maternal benefits of breastfeeding (6)

Answer 5

• decreased postpartum bleeding/more rapid uterine involution
• lactational amenorrhea
• earlier return to pre-pregnant weight
• improved bone remineralization
• decreased cost
• ready availability

Question 6

Breast milk nutrients

Answer 6

• carbohydrates (lactose)
• Lipids (50%)
• Proteins (70% whey, 30% casein)

Question 7

Common breastfeeding problems (5)

Answer 7

• enlarged/tender breasts
• improper latch/suckle
• prolonged feedings
• infants fall asleep before finishing
• maternal inexperience/anxiety

Question 8

Hereditary forms of hemolysis (3)

Answer 8

• intrinsic cell membrane defects (spherocytosis, elliptocytosis)
• enzyme disorders (G6PD deficiency, pyruvate kinase deficiency)
• hemoglobinopathies (thalassemias, SCD)

Question 9

Biliary atresia (3 signs, evaluation, treatment)

Answer 9

• jaundice, dark urine, acholic (pale) stools between 3-6 wks of age
• check fractionated bilirubin
• Kasai surgical procedure

Question 10

Major risk factors for severe hyperbilirubinemia (TSB>95th %ile) (8)

Answer 10

• pre-discharge TSB or TcB in high-risk zone
• jaundice in first 24 hours of life
• blood group incompatibility
• gestational age 35-36 weeks
• previous sibling received phototherapy
• cephalohematoma or significant bruising
• exclusive breastfeeding
• east asian

Question 11

Minor risk factors for severe hyperbilirubinemia (6)

Answer 11

• pre-dischqarge TSB or TcB in high intermediate risk zone
• gestational age 37-38 weeks
• jaundice observed before discharge
• previous sibling with jaundice
• macrosomic infant of diabetic mother
• maternal age >25
• male gender

Question 12

Decreased risk for severe hyperbilirubinemia (5)

Answer 12

• TSB or TcB leve in low-risk zone
• gestational age 41 weeks
• exclusive formula feeding
• black
• discharge from hospital after 72 hours

Question 13

Management of persistent jaundice (2-12wks)(3)

Answer 13

• check for dark urine or acholic-appearing stools (cholestasis)
• fractionated bilirubin levels (trend)
• biliary atresia/A1AT deficiency