Filiz Bakar

Question 1

Newborn average weight,length,head circunference, respiratory rate, pulse

Answer 1

3.2kg
50 cm
35 cm
40-60 breath
100-180

Question 2

Newborn examination

Answer 2

Does baby look ill or well
color( cyanosis, jaundice,pale) Perioral/acrocyanosis normal
Active? Semiflexion, light hypertonism normal. Spastic/hypotonic not normal
Cry
Measurements, growth chart
Vitals
Fontanelles(bulging,sunken,molding, caput-swelling of scalp from pressure, cephalhematoma- hemorrhage under periosteum), hydrocephalus,bruising
Malformations:face:
chin:micrognathia
Mouth and palate: ranula,ebstein pearls,natal teeth,bifid uvula normal, frenulum,macroglossia,moniliasis, cleft lift palate
Nose:choanal atresia

Question 3

Neonatal hyperbilirubinemia

Answer 3

Significant hyperb: TB> 95th percentile on hour specific nomogram
Severe hyperb: TB>25 at risk for bilirubin induced neurologic dyfunction
Bilirubin crosses BBB, neurotoxicity, kern
BBB nonexistent first week to 10 days so hyperbilirubinemia very important

Question 4

Bilirubin testing ways

Answer 4

Visuel
Transvutaneous (TcB) measurement
Capillary venous total bilirubin(TB)

Question 5

Bilirubin metabolism

Answer 5

RBC hemolysis
Heme
Biliverdin
Bilirubin
1.enterohepatic:
Bilirubin-albumin
Bilirubin-ligandin
Conjugated bilirubin(bile duct to bowels)
By beta glucuronidase: unconjugated bil.
Urobilinogen
2. Free bilirubin

Question 6

Case:
4 days baby with 2 days jaundice, skin sclera yellow, no pallor
Reddish orange stain on diaper
Weight loss above %10
No other problem
TcB:14~ low intermediate risk zone

Answer 6

Benign neonatal hyperbilirubinemia=
Physiologic jaundice

Occurs in most newborns
Normal,, Happenes because
1.fetal rbc shorter life span and increased turnover after birth
2.bilirubin clearance decreased
3.increase in enterohepatic circulation of bilirubin

Mean TB peaks at 48 to 96 hours
East asian 72-120 h
95th percentile 13 to 18, ranges
Jaundice resolves 1-2 weeks after birth

See baby next day for weight and bilirubin

Question 7

Case/
5 days old. Jaundice since 3rd day. Poor oral intake, lethargy, takes breast milk
Family is low socioeconomic
Other sibling suffered from jaundice too
Mother 0+, father uknown

Severe jaundice, high pitched cry, hypertonia, periodic breathing with apnea, opisthotonus(these sign neurologic involvement)

TB: 36/2,5 very high
Blood group: A+
Direct coomb: +( rh uyuşmazlığı kesin pozitif, ab0 uyuşmazlığı belki)
Hb: 12 düşük
Reticulocyte:%7( signals yıkım, üretim)
İnfection negative

Answer 7

AB0 incompatibility
ACUTE BİLİRUBİN ENCEPHALOPATHY

Trx:
exchange transfusion
Phototherapy

Later, at 18 months:
Severe neuromotor impairment
Choreo-athetoid movements
İmpaired upward vertical gaze
Hearing loss
: CHRONİC BİLİRUBİN ENCEPHALOPATHY

Question 8

SİGNİFİCANT UNCONJUGATED HYPERBİLİRUBİNEMİA causes

Answer 8

1.INCREASED PRODUCTİON:
ABO/ Rh uyuşmazlığı
membrane defects: Hereditary spherocytosis , elliptocytosis
Enzymatic defects: G6PD deficiency, pyruvate kinase def. Congenital erytheopoietic porphyria
Sepsis
Polycytemia or cephalohematomas
Macrosomic infants of diabetic mothers (polycytemia,ineffective eryhtropoiesis)
2. DECREASED CLEARANCE:
Criggler najjar syndrome!
Gilbert syndrome!
Congenital hypothyroidism, panhypopituitarism
Galactosemia,maternal diabetes
3. INCREASED ENTEROHEPATİC CİRCULATİON:
Breast milk jaundice
İleus/ intestinal obstruction
4.LACTATİON FAİLURE JAUNDİCE:
Inadequate intake of fluid and calorie so hypovolemia, weight loss, hypernatremia

3.INCREASED ENTEROHEPATİC CİRCULATİON OF BİLİRUBİN:
Breast milk jaundice
İleus/ intestinal obstruction

4.LACTATİON FAİLURE

Question 9

Hyperbilirubinemia general causes

Answer 9

Specific pathologic conditions
Exagarations of mechanisms responsible for normal phsyiologic jaundice

• increased hemolysis
  -hepatic function
  -gut function

Question 10

Bilirubin induced neurologic injury

Answer 10

1. ACUTE BİLİRUBİN ENCEPHALOPATHY:
   Decreased feeding
   Lethargy
   Abnormal tone
   Seizures
   High pitched cry
   fever
   Apnea
   Kernicterus facies(scared): setting sun sign+ eyelid retraction
   2.CHRONİC BİLİRUBİN ENCEPHALOPATHY( KERNİCTERUS):
   Tetrad:
2. Choreoathetoid cerebral palsy
3. Hearing loss
4. Limitation of upward gaze
   4.dental enamel hypoplasia

Kernicterus face, opisthotonus, enamel dysplasia

Question 11

Screening for hyperbilirubinemi

Answer 11

Clinical, bilirubin measurement, follow up

All infants assesed for jaundice every 8-12 hours transcutan.
Bilirubin measurement for:
- jaundice before 24 hours
-excessive jaundice( below umbilicus)
-failure of jaundice resolution, 14-21 days in breastfed, 7 days formula fed
-still jaundiced at 2 weeks: direct/ conjugated bilirubin testing

Question 12

Risk factors for severe hyperbilirubinemia

Answer 12

Albumin<3
Known hemolytic disease
Sepsis
İnstability first 24 hours

Question 13

Additional tests for infants meeting criteria of phototherapy

Answer 13

Blood type, direct Coombs test
CBC and smear
Reticulocyte count
G6PD