Neonatal Conditions

Question 1

Name risk factors for neonatal jaundice (4)

Answer 1

• Gestational age under 38 weeks
• A previous sibling with neonatal jaundice requiring phototherapy
• Mother’s intention to breastfeed exclusively
• Visible jaundice in the first 24 hours of life

Question 2

All babies with neonatal jaundice should receive the following investigations: (4)

Answer 2

• Serum bilirubin (for baseline level to assess response to treatment).
• Blood packed cell volume.
• Blood group (mother and baby).
• DAT (direct anti globulin test). Interpret the result taking account of the strength of reaction, and whether mother received prophylactic anti-D immunoglobulin during pregnancy.

Question 3

What additional investigations might you consider in a baby with neonatal jaundice? (3)

Answer 3

• Full blood count and examination of blood film
• Blood glucose-6-phosphate dehydrogenase levels, taking account of ethnic origin
• Microbiological cultures of blood, urine and/or cerebrospinal fluid (if infection is suspected).

Question 4

How do you decide on treatment for neonatal jaundice?

Answer 4

Using a neonatal jaundice threshold chart. The bilirubin threshold for phototherapy and exchange transfusion varies depending on gestational age.

Question 5

What are some precautions needed for phototherapy? (4)

Answer 5

• Expose skin to ensure effectiveness
• Cover eyes to prevent damage
• Sometimes need NG feeding to maximise time under lights If severe
• Ensure adequate hydration and monitor temperature of baby

Question 6

What bilirubin monitoring needs to occur after initiating phototherapy?

Answer 6

Repeat the serum bilirubin measurement 4–6 hours after initiating phototherapy. Repeat serum bilirubin measurement every 6–12 hours when the serum bilirubin level is stable or falling.

Question 7

When should you stop phototherapy?

Answer 7

Once 50 below phototherapy threshold check for rebound of significant hyperbilirubinaemia with a repeat serum bilirubin measurement 12–18 hours after stopping phototherapy. Babies do not necessarily have to remain in hospital for this to be done.

Question 8

When would you consider intensified (extra lights/ intensity) phototherapy?

Answer 8

If bilirubin is within 50 of exchange transfusion threshold.

Question 9

Most common cause of simple physiological neonatal jaundice?

Answer 9

The breakdown of fetal hemoglobin (as excessive Hb is needed in utero) is replaced with adult hemoglobin and the relatively immature metabolic pathways of the liver are unable to conjugate and excrete bilirubin as quickly as an adult. This causes an accumulation of bilirubin in the blood (hyperbilirubinemia), leading to the symptoms of jaundice.

Question 10

Underlying pathological causes of neonatal jaundice? (persistent despite phototherapy)

Answer 10

• Biliary atresia (pale stools and dark urine also)
• Progressive familial intrahepatic cholestasis
• alpha 1-antitrypsin deficiency
• Hep B and A
• Infections/ sepsis of all kinds
• Sickle Cell
• Alpha Thallassaemia
• G6DP Deficiency
• Cephalohaematoma
• Haemolytic disease of the newborn
• TORCH infections
• CF
• High GI obstruction e.g. pyloric stenosis
• Hypothyroid/ pituitary

Question 11

Epidemiology of neonatal jaundice

Answer 11

An estimated 50% of term and 80% of preterm infants develop jaundice, typically 2-4 days afer birth

Question 12

What are the TORCH infections? ( can cause neonatal jaundice)

Answer 12

Toxoplasmosis
Other (such as syphilis, varicella, mumps, parvovirus and HIV)
Rubella
Cytomegalovirus
Herpes simplex

Question 13

What are the risks of neonatal jaundice and how does this present?

Answer 13

Kernicterus (aka bilirubin encephalopathy) is a rare but serious complication of untreated jaundice in babies. It’s caused by excess bilirubin damaging the brain or central nervous system. Signs include:

• Reduced GCS
• Their muscles become unusually floppy, like a rag doll
• Poor feeding
• As kernicterus progresses, additional symptoms can include seizures and arching of the neck or spine.

Question 14

Typical features of physiological jaundice and pathological jaundice.

Answer 14

Starts at day 2-3, peaks day 5 and usually resolved by day 10. The baby remains well and does not require any intervention beyond routine neonatal care.

Jaundice starting before 24hours of life is more likely to pathological. Jaundice for >14 days in term infants and 21 days in preterm, consider other causes.

Question 15

How do you measure bilirubin levels?

Answer 15

Transcutaneous bilirubinometer (TCB) can be used in >35/40 gestation and >24 hours old for first measurement.

Serum bilirubin to be measured if <35/40 gestation, <24 hours old or TCB >250 µmol/L

A total and conjugated bilirubin is important if suspecting pathology.

Question 16

Features of breastfeeding jaundice

Answer 16

• Usually resolves in about 4 months

- 10% of exclusively breastfed babies will be jaundiced at 1 month.