Jaundice in a neonate/child Flashcards
What % of term/preterm babies develop jaundice?
Approximately 60% of term and 80% of preterm babies develop jaundice in the first week of life, and about 10% of breastfed babies are still jaundiced at 1 month.
Name 5 causes of neonatal jaundice.
- Blood group incompatibility - rhesus or ABO incompatibility
- Haemolysis e.g. deficiency of G6PD (glucose-6-phosphate-dehydrogenase) can cause severe neonatal jaundice
- Sepsis
- Liver disease
- Bruising
- Metabolic disorders
Why does breasfeeding increase risk of jaundice in neonates?
Early onset type is probably secondary to delayed milk production and poor feeding, leading to decreased caloric intake and dehydration and resulting in higher total serum bilirubin levels and reabsorption from the gut.
Late onset type is thought to be caused by increased enterohepatic circulation of bilirubin. Various factors in breast milk have been implicated, including 3-alpha 20-beta pregnanediol, non-esterified free fatty acids (that inhibit hepatic glucuronyl transferase), lipoprotein lipase, and beta-glucuronidase activities.
Which type of bilirubin can cause kernicterus?
Unconjugated bilirubin is made from RBC breakdown which is mostly bound to albumin but some is free.
Free unconjugated bilirubin can penetrate the blood-brain-barrier and can be toxic to neural tissue
This can cause acute or chronic bilirubin encephalopathy.
What are the thresholds for starting treatment?
Depend on age (hours) and the bilirubin measurement (micromol/L).
E.g. for a baby of age 24 hours, >200 micromol/L bilirubin would indicate phototherapy but >300 micromol/L would indicate need for exchange transfusion (unless bili falls to lower levels while treatement is being prepared)
https://www.nice.org.uk/guidance/cg98/chapter/Recommendations
Can breastfeeding continue if baby is jaundiced?
Yes. It is harmless and very common and parents should be reassured. However, they should look out for chalky stools and dark urine in nappies.
What factors increase babies’ risk of developing hyperbilirubinaemia?
- gestational age <38 weeks
- FH in siblings
- mother’s intention to only breastfeed
- jaundice in the first 24hrs of life
How do you examine a baby for jaundice?
- Sclera, gums, on ‘blanched’ skin by pressing
- In bright natural light
What investigations should you do if the baby is visibly janudiced in the first 24 hours of life?
Measure serum bilirubin every 6 hours until both:
- below the treatment threshold
- stable and/or falling
When should you use serum bilirubin measurement vs transcutaneous bilirubinometer?
Transcutaenous bilirubinometer - if gestational age >35 weeks. If result is >250 micromol/L then measure serum bilirubin.
Serum bilirubin - if gestational age <35 weeks OR in the first 24 hours of life. This is total bilirubin.
How often should you repeat the bilirubin measurement if it falls to >50micromol/L below the threshold for their age?
- 18hrs - if any risk factor like FH or mother exclusively breastfeeding
- 24hrs - if no risk factors
This will tell you whether phototherapy needs to be started. Same timings for if they have remained within 50micromol/L of the threshold for some time.
How often during phototherapy should you repeat the bilirubin measurement?
every 4-6 hours
(or every 6-12hrs if falling or stable)
When should you consider high intensity phototherapy to treat hyperbilirubinaemia?
- Serum bilirubin rising rapidly (>8.5micromol/L/hr)
- Within 50micromol/L of threshold for exchange transfusion
- Failure to respond to initial 6hrs of phototherapy
What precautions should be taken for the baby during phototherapy?
Eye protection and routine eye care
Alternatively, tinted headboxes can be used
Can breaks be taken from the phototherapy?
Yes, breaks for nappy changing, cuddles and breastfeeding of up to 30 min are encouraged
HOWEVER, intensified phototherapy should not be interrupted for feeding. Consider enteral feeds/IV
