jaundice Flashcards
jaundice
unconjugated hyperbilirubinemia can have serious conseq- kernicterus, nuro impairment, brain damage, encephalopathy
bilirubin pthwy
hg –> unconjugated bili= insoluble in aqueous soln –> bind albumin in blood –> liver extract it –> bind cystosolic protein –> conjugated with glcuronide by UDPGT= glycyronosyl transferase –> water soluble –> excrete in bile –> GI (in adult flora convert to urobilin- excrete) in baby no flora –> beta glucuronidase in meconium hydrolyze it back to unconjugated form –> reabsorbed into blood –> bind albumin= enterohepatic circulation
kernicterus
staining of basal ganglia and CN nuclei by bili. result from toxic lvl of UCB. may lose suck reflex, become lethargic, dev hyper irritability and seizure, die. if survive may get opisthotonus, rigidity, oculomotor paralysis, tremors, hearing loss, ataxia.
hemolysis from ph incompatibility. screen decr this.
physiological jaundice
Tbili
jaundice associated with breastfeeding
1) breastfeeding jaundice
2) breast milk jaundice
breastfeeding jaundice aka lack of milk jaundice
1) early in the first week of life and occurs when the milk supply is relatively or absolutely low, resulting in limited enteral intake.
2)The low intake results in decreased gastrointestinal motility that in turn promotes retention of meconium.
3) The β-glucuronidase in meconium deconjugates bilirubin and the unconjugated bilirubin is reabsorbed via the enterohepatic circulation, causing an elevation of serum levels.
4) Breast milk production typically increases greatly once “let-down” occurs.
Occasionally, persistently low volume of breast milk can cause the neonate to become dehydrated and malnourished.
breast milk jaundice
1) Begins in the first 4 to 7 days of life but may not peak until about 10 to 14 days.
2) Not the result of low breast milk volume.
3)While the cause is not completely understood, one explanation is that β-glucuronidase present in breast milk deconjugates bilirubin in the intestinal tract; the unconjugated bilirubin is then reabsorbed via enterohepatic circulation.
4) Breast-milk jaundice can persist for up to 12 weeks, but total bilirubin concentration rarely, if ever, reaches concerning levels.
The time course of breast-milk jaundice is quite different from that of physiologic jaundice.
tx: continue feeding. reck in 24hr
hemolysis
direct coombs- ab pos hymolsysi= direct ab test pos (DAT)
rh incompatibility, ABO incompatibility, incomp minor blood ag, ab neg hemolysis in infant with RC mem defect- spherocyte or G6P dehydrogenase or pyruate kinase def.
other causes of jaundice
non-hemolytic RBC breakdown- bruising from birth trauma, large cephalohematoma or other hemorrhage, polycythemia, swallowed blood during delivery
metabolic error- crippler nadir syndrome, galactosemia and hypothyroidism
etnicicty- asin > caucasian
crigler najjar syndrome
hyperbilirubinemia results from decreased bilirubin clearance caused by deficient or completely absent UDPGT.
nursing
8-12/24hr. 10-15min at each breast.
chart review in jaundice
when jaundice start (by d 4-5 r/o physiological and severe hemolysis). wt hx- if don’t gain- indicate insufficient fluid and calorie intake- dx breastfeeding jaundice
feeding hx
preg hx- maternal infection in utero –> IUGR
illness in newborn- temp instbaility, respiratory distress, apnea, irritability, lethargy, poor tone, vomiting, poor feeding
Glucose 6 phosphate dehydrogenase def (G6PD)
more common in mediterranean. x linked. result in hemolysis and jaundice.
newborn voiding
day 3- 3-4/d
day 6 6-8/d
pale yellow
newborn stool
day 3- meconium stop. bowel mV yellow
6-7: 3-4 stools/d.
if lose color= echoic- sign of biliary atresia
biliary atresia
A healthy-appearing infant who develops jaundice, dark urine, and acholic (pale) stools between 3 and 6 weeks of age
dx early- tx surgically with Kasai procedure (anastomosis of the intrahepatic bile ducts to a loop of intestine to allow bile to drain directly into the intestine).
Vit D
supplemented for exclusively breastfed infants for 1st 6mo. prevent rickets (appear in 6-24mo)
iron
supplemented for after 6mo not bf expect anemic or low fe due to prematurity. it is in breastmilk. can’ support adequate hg production.
fluoride
breast and bottle fed infant should be sup after 6mo if water lacks it.
bilirubin lvl v body
4-5 face
10-15- below knee
indications of birth trauma
cephalohematoma- subperiosteal hemorrhage. swelling doens’t extend past suture line.
bruising
fontanelle
anterior palapable later, posterior never palpable
gilbert syndrome
reduced activity of the enzyme glucuronyltransferase) is a relatively common cause of harmless jaundice (~5% of the population).
Final diagnosis usually does not occur until later in life, when it is found that hyperbilirubinemia persists, with no other abnormalities.
TORCH
can lead to jaundice.
Physical findings may include hepatosplenomegaly, microcephaly, and/or rash.
neonatal screen v jaundice
hypothyroidism and galactosemia are two things screened that can cause jaundice
persistent jaundice
can last up to 12wk. ck for dark urine or echoic appearing stool- cholestatsis. DB- make sure not rising.
evaluate if
J 5-8 in 24hr, rate of bili rise >.5/h= hemolysis
evaluate methods
indirect- CBC, reticulocyte count, smear, sepsis
direct- hepatic US, serology for viral hep, radioisotope scan of hepatobiliary tree
bilirubin v brain structure
go to basal ganglia, hippo, brainstem causing choreoathetoid cerebral palsy, hearing loss, opisthotonus, seizure, oculomotor paralysis
