Neonatal Jaundice Flashcards
1
Q
Causes of neonatal jaundice <24hrs
A
This is ABNORMAL
- Haemolysis:
- Rhesus/ABO incompatibility
- Affects group O women
- IgG anti-A haemolysin antibodies (anti-B less common)
- IgG can cross placenta, IgM can’t
- Genetic:
- G6PD / Pyruvate kinase def.
- Hereditary spherocytosis
- Infection
- Metabolic
- Gilberts (infectious trigger)
- Crigler-Najjar (glucoronyl transferase deficiency -> cant make cBR)
- Dubin-Johnson
2
Q
Investigations for neonatal jaundice <24hrs
A
First ADMIT child
-
Direct (total) serum BR taken within 6hrs of presentation
- Assume total BR = uBR since unlikely to be conjugated
- Blood film -> ?spherocytosis
- FBC + Haematocrit
- Blood group of baby + mother (ABO)
- G6PD levels
- If suspecting infection: MC&S of blood + urine ± CSF
- Assess risk for kernicterus
- Serum BR >340 (for >37wks GA)
- Rapidly rising BR >8.5 per hour
- Clinical features of kernicterus
- Poor feeding
- Extreme lethargy
- Hypotonia
- High-pitch cry
*
3
Q
Causes of neonatal jaundice 2 days to 2wks
A
Common, can be NORMAL
- 40-60% = Physiological jaundice
- Commonly day 1-7
-
10% = Breastfeeding jaundice
- Lack of effective breastfeeding
- Increased enterehepatic recycling
-
<2% = Breastmilk jaundice
- Decreased UGT1A1 activity
- Occurs after physiological jaundice
Other:
-
Haemolysis (G6PD/PK def, Hereditary Spherocytosis)
- Unlikely to be ABO/Rh incompatibility - would have presented earlier
- Metabolic (Gilbert’s, Crigler-Najjar, Dubin-Johnson)
- Infection
- Congenital hypothyroidism
- Dehydration, bruising (cephalohaematoma), polycythaemia (can make jaundice more apparent)
4
Q
Investigations for jaundice 2 days to 2wks
A
Admit if >7days
- TRANSCUTANEOUS BR (assume as uBR) within 6hrs of presentation
- If result >250, confirm again using serum BR
- FBC + haematocrit
- Blood film -> ?spherocytosis
- G6PD levels
- TSH levels -> ?congenital hypothyroidism
5
Q
Causes of neonatal jaundice >2wks
A
Can be NORMAL
Unconjugated BR causes:
- ONGOING causes from 2-14days
- Breastmilk + Physiological jaundice most common
- Pyloric stenosis (presents 2-4wks)
- Congenital hypothyroidism
Conjugated BR causes:
- Congenital hypothyroidism
- Biliary atresia (Asymptomatic, always hungry, pale stools)
- Kasai’s portoenterostomy
- Hereditary metabolic conditions (Gal-1-PUT def., A
- Ascending cholangitis
- Cystic Fibrosis
- Idiopathic neonatal hepatitis
6
Q
Management of neonatal jaundice?
A
Physiological = Reassure + Observation
Pathological Unconjugated:
- Acute bilirubin encephalopathy (Kernicterus)
- Immediate exchange transfusion
- Phototherapy
- Hydrate
- IVIG (for Rh/ABO haemolysis)
- Total bilirubin >95th centile for Phototherapy
- Phototherapy
- Hydration
- Total bilirubin >95th centile for Exchange transfusion
- Exchange transfusion (folic acid afterwards to prevent anaemia)
- Phototherapy
- Hydration
- IVIG
Pathological Conjugated = Treat underlying cause (e.g. surgery for biliary atresia)
Breastmilk jaundice = Manage according to bilirubin levels. Can usually continue breastfeeding as normal
7
Q
Counsel for phototherapy
A
- Generally very effective, doesn’t cause any harm to baby, has very few side effects
- A special type of light shines on the skin, which converts the bilirubin into a form that can be more easily broken down by the liver and passed out of the baby’s blood via pee
- Baby will be placed in a cot with their eyes covered
- Treatment can be stopped for breaks lasting 30mins to breastfeed/change nappy/cuddle
- We encourage frequent breastfeeding during therapy (e.g. every 3hrs)
- During the therapy baby’s temp will be monitored so they don’t get too hot, and we’ll also monitor for dehydration
- Blood tests every 4-6hrs to monitor bilirubin levels and see if therapy is working
- Once levels are safe/start to fall, we’ll check every 6-12hrs
- Therapy will be stopped when bilirubin falls to safe level, which usually takes a day or two.
- After therapy has stopped, need to stay in a bit longer to check for rebound hyperbilirubinaemia
- If baby’s jaundice doesn’t improve, we may offer intensified phototherapy
- Exactly the same but more intense light
- However can’t take any breaks
8
Q
Counsel for exchange transfusion
A
- If your baby has a very high level of bilirubin in their blood or phototherapy has not been effective, they may need a complete blood transfusion, known as an exchange transfusion.
- During an exchange transfusion, your baby’s blood will be removed through a thin plastic tube placed in blood vessels in their umbilical cord, arms or legs.
- The blood is replaced with blood from a suitable matching donor (same blood group)
- As the new blood will not contain bilirubin, the overall level of bilirubin in your baby’s blood will fall quickly.
- Your baby will be closely monitored throughout the transfusion, which can take several hours to complete. Any problems that may arise, such as bleeding, will be treated.
- Your baby’s blood will be tested within 2 hours of treatment to check if it’s been successful.
- If the level of bilirubin in your baby’s blood remains high, the procedure may need to be repeated.
9
Q
Counsel for breastmilk jaundice
A
- Breastfeeding your baby can increase their chances of developing jaundice.
- But there’s no need to stop breastfeeding your baby if they have jaundice, because the symptoms normally pass in 2 weeks.
- Some breastfed babies can have jaundice for as long as 12 weeks, but it’s important that this is checked by a health visitor or GP so other more serious causes of jaundice can be ruled out.
- The benefits of breastfeeding outweigh any potential risks associated with the condition.
- If your baby needs to be treated for jaundice, they may need extra fluids and more frequent feeds during treatment.
10
Q
Counsel for breastfeeding jaundice (a.k.a. sub-optimal intake jaundice)
A
- Baby not receiving optimal amount of milk
- This leads to more reabsorption of bilirubin in the intestines
- Inadequate milk also delays passage of meconium, which contains lots of bilirubin as well -> bilirubin transferred to baby’s blood
- Breastfeeding can and should continue
- More feeding can reduce jaundice
