Jaundice Flashcards
Common causes of jaundice in the newborn
Unconjugated hyperbilirubinaemia - Prematurity - Rhesus incompatibility - ABO incompatibility - Infection - Bruisiing - Hypothroidism - Breast milk jaundice - Physiological Conjugated hyperbilirubinaemia - Hepatitis- Neonatal hepatitis or Hep A,B,C, Congenital viral infection eg CMV, Inborn errors of metabolism eg galactosaemia, Abnromal LFT. - Cystic fibrosis - Cholestasis - Choledocal cyst - Biliary atresia - Red flag.
Jaundice in the first 24 hrs of life
Red flag - needs special care nursery and Ix
Causes
- Mostly haemolytic eg ABO Ro Rhesus incompatibility.
Ix - Mother and baby blood group, serum bilirubin, direct coombs’s test, Hb, WCC, PLTs. Mother’s antibodies.
Mx - Phototherapy if greater then150micromol/L if term infant. Immediate exchange transfusion if due to Rhesus incompatibility and HB less than 110g/L
Monitor bilirubin and plot of graft to see when action level is crossed
Jaundice in day 2-7
Considered physiological if the following criteria is meet
- Jaundice appeared on day 2-4
- Baby is not premature
- Baby is well- a febrile, feeding well and alert
- Baby is passing normal coloured stools and urine
- No other abnormalities
- Bilirubin levels are below Tx threshold.
Jaundice is visible when bilirubin is above 85-120 micro mol/L
If above 220 than consider other causes eg infection
What is kernicterus
Brain damage due to high bilirubin - above 340 micro mol/L
Deposited in basal ganglia
Causes acute encephalopathy with irritability, high pitched cry or coma. Can lead to athetoid cerebral palsy.
At risk baby’s are unwell infants, infants with haemolytic and preterm infants.
Tx Jaundice at lower levels in these infants.
Prolonged Jaundice of greater than 14 days
In well infant it is usually secondary to breastfeeding (10% of infants).
Check bilirubin to determine is conjugated or unconjugated
Unconjugated - Hypothroidism, infection or RBC enzymes abnormalities. If sudden onset then suggestive of G6PD deficiency and will need urgent admission.
Conjugated - Uncommon and pathological. Consider biliary atresia (the stools are acholic- grey colour), neonatal hepatitis (CMV, Toxo, rubella, syphilis, EBV, Parvovirus), Chledochal cyst obstructing duct, galactosaemia or parenteral nutrition, Cystic fibrosis bacterial infection
All must have conjugate vs unconjugated levels check
Assume Biliary atresia until proven otherwise. (Pale stools and dark urine).
Psychological Jaundice
Very common
Usually due to low liver enzymes and breakdown of fetal HB
Self limiting as liver enzymes mature over the first week.
nearly all preterm infant become jaundice in first days. May require phototherapy
Breast milk Jaundice
Occurs in well baby who is breast fed. Usually develops in 2rd week.
Normal coloured stools and urine.
Causes - inhibition of liver conjugation by substances in breast milk.
Dx of exclusion - Need to measure bilirubin to exclude conjugated cause.
Normal manifest day 4-7 and persist for 3 weeks to 3 months.
Haemolytic disease of newborn
Cause when maternal IgG AB cross placenta and reacts with fatal RBC Ag.
Commonest cause ABO or rhesus incompatibility.
Prevention of Rhesus incompatibility is to immunise mother with Anti D AB at 28 weeks, If missed fetus can get Hydrops due to severe anaemia.
Mx
Deliver before severe haemolytic occurred and wash out with series of exchange transfusion and aggressive use of early phototherapy.
AB can persist of weeks
Biliary atresia
Rare but important - red flag
Absence of intra or extra hepatic bile duct.
Causes conjugated hyperbilirubinaemia over weeks and stools become clay coloured.
Consequence if un Dx - liver failure and death
Mx
- in first 6 was - Kasai procedure - Hepatoporto- enterstomy.
- All baby’s with greater than 2 wk jaundice need conjugated/unconjugated levels checked. If conjugated is greater then 20% of total when refer.
- Refer to paediatric hepatologist for assessment
- Need Modified formula for Fat that do not require bile for absorption as well as Vitamin A,D and E.
Prognosis - for favoriatable outcome Dx before 6 was.
Jaundice in older children
Rare
Cause - generally hepatitis or chronic liver disease
Commonest cause is hep A.
Others - chronic haemolytic due to Hereditary spherocytosis or G6PD deficiency or liver disease such as autoimmune chronic hepatitis.
Reye’s syndrome - acute encephalopathy associated with fulminant liver failure due to aspirin.
Paracetamol OD
Wilson’s disease - neurodevelopmental delay and liver failure. Brown Kayser-Fleischer rings in cornea.
Chronic Jaundice - Criggler Najar disease - defect in glucuronyl transferase deficiency or abnormal hepatic uptake of bilirubin as Gilbert syndrome.
Hx Q for Jaundice
When did it start and duration
Risk factor for infection
Fm Hx - CF or spherocytosis
Is baby alert, active, feeding week or lethargic and having to be woken for feeds (significant jaundice)
Ex of Jaundice
How far down is the jaundice
Other features eg congenital viral infection (petechia with, anaemia or Hepatosplenomegaly.)
Hydration - Failure to establish Breast feeding may present as severe jaundice and hypernatraemia in the first week
Is the baby well or are there signs of infection
Examine the stool
Ix for Jaundice
Split bilirubin - conjugated should be less then 20%
FBC - trhombocytopenia suggest viral infection or IUGR, Anaemia in haemolytic disease, Neutropenia or neutrophilia in infection
Group and combs - ABO and Rhesus incompatibility
TFT - Hypothyroidism
TORCH screen - Hep B, CMV
LFT - High ALT suggest Hepatitis
Urine metabolic screen- Inborn errors of metabolism
Liver USS - biliary tree
Infection screen - Urine, blood and CSF
Liver isotope scan - rule out biliary atresia
Coagulation - affected with liver disease and Vit K deficiency.
