Neonatal jaundice Flashcards
Etiology
1.UnConjugated
a. Physiologic
b. Pathologic
–>i. Hemolytic
Membrane
Enzyme
Hemaglobin
Immune: ABO, Ph
Non-immune: Splenomegaly, sepsis, AV malformation
–>ii. Non-hemolytic
Hematoma
Polycythemia
Sepsis
HypoT
Gilberts
- Conjugated (always pathologic)
a. Hepatic
Infectious: sepsis, TORCH, hep B
Metabolic: galactosemia, A1AT, CF, hypoT
Drugs
TPN
Idiopathic neonatal hepatitis
b. Post hepatic
Biliary stresia
Choledochal cyst
When is jaundice visible
- When levels 85-120umol/L
When is jaundice more severe/prolonged
- Prematurity
- Acidosis
- Hypoalbuminemia
- Dehydration
How common is jaundice
- 60% of term infants develop jaundice
Onset and progression of physiologic jaundice, pathophysiology
- Onset at day 2-3 of life, resolution by day 7
- PathoP
+RBC number and shortened lifestyle
Immature glocorynyl transferase->poor conjugation
+Enterohepatic circulation
Decreased uptake and binding by liver cells
Breastfeeding jaundice
- Due to lack of milk supply->dehydration->more exagerated physiologic jaundice
Breastmilk jaundice, cause, progress
- 1 per 200 infants
- Glocorinyl transferase inhibitor in the milk
- Onset day 7 of life->peaks at 2-3 weeks and resolves by 6 weeks.
When should pathologic jaundice be considered
- When
Risk factors
1. Maternal Ethnic Asian Complications during pregnancy->Rh, ABO, diabetes Breastfeeding 2. Perinatal Birth trauma->cephalohematom Prematurity 3. Neonatal DIfficulty establishing breast feeding->deH Infection Genetic, metabolic Polycythemia Drugs
Initial assessment of all babies with jaundice
1. Assess for risk factors for jaundice and significant hyperbilirubinemia ?family history of hemolysis 6. Examination Feeding Weight Hydration Risks: preterm, 2 weeks 7. Identify the cause if not clear from history/examination Total serum bilirubin FBC + film Blood group maternal and baby DAT NBST if applicable 8. Refer to pediatrician/neonatologist if results abnormal 9. Fluid management
If
Medical emergency
- Measure and record serum bilirubin within 2 hours
- Manage as per treatment graphs
- Neonatalogy/pediatrician review within 6 hours
- Commence phototherapy whilst awaiting results
- Do investigations
- Manage fluids
24 hours to 10 days
- Measure and record TcB or serum bilirubin w/i 6 hours
- Manage as per treatment line
- Commence phototherapy if >6 hours for results, baby has risk factors, TCB >250mmol/L or above treatment threshold, jaundice below the nipple
- Medical review required
- DO investigations if cause not obvious
- Manage fluids
- Be sure to treat underlying sepsis
- Arrange F/U with midwife/GP to ensure adequate oral intake
2 weeks for term, >3 weeks for preterm
Prolonged jaundice management
- Usually breastfeeding related
- Investgate
Total and conjugated bilirubin
FBC + film
Reticulocyte count
Blood group
DAT
TFTs
Review NBST - Seek expert advice if +conjugated, dark urine and pale stools
- Fluid management
- Consider additional investigations
Signs of acute bilirubin encephalopathy
- Bilirubin toxicity in first few weeks of life
- Lethargic
- Irritable, temperature instability, opisthotonos, spasticity
- Apnea
- Hypotonia, poor sucking reflex->hypertonic, high pitched cry, seizures and coma
Definition and manifestations of chronic bilirubin encephalopathy
Clinical findings of chronic bilirubin encephalopathy include
o Athetoid cerebral palsy with or without seizures
o Developmental delay
o Hearing deficit
o Oculomotor disturbances including paralysis of upward gaze
(Parinaud’s sign)
o Dental dysplasia
o Intellectual impairment
Define kernicterus
- Yellow staining of basal ganglia
2. Frequently used to refer to the clinical sequelae
When is kasai procedure best done
- Before 45-60 days of life
Prevention of jaundice
- Early and frequent breastfeeding
- Blood group, Rh, Coombs test on cord blood if mothers blood group is negative or unknown
- Risk assessment before d/c and plan f/u
- Monitor all infants for jaundice 12 horly
What is Kramer’s rule
- The level of jaundice on infant->face->trunk->arms and legs can crudely correspond to serum bilirubin level
Infants at higher, medium and lower risk
1. Higher 35-37 + risk factors 2. Medium 38 + risk factors 3. Low 38 + well
Brief overview Mx
- Fluids
- Phototherapy
- Exchange transfusion
- IV immunoglobulin if hemolytic and not responding
How does phototherapy work
- Exposure to light photoisomerises unconjugated bilirubin->+solubility->can then be excreted in feces and urine
- Blue light is best 460-490nm
How to increase effectiveness of phototherapy
- +amount of skin exposed
- +intensity of the light
- Additional overhead light
- Closer light to baby
Biliblanket
- Outpatient
2. Allows therapy in open cot with mum on ward
Monitoring phototherapy and cessation
- Adequacy hydration and nutrition, continue breastfeeding
- Temperature
- Clinical improvement
- Potential signs of bilirubin encephalopathy
- Cease when SBR
Potential complications of phototherapy
- Overheat
- Water loss, diarrhea->hydration
- Rash
- Parental anxiety/separation->educate and reassure
- Ileus->bowel motions, distention
- ?Retinal damage
- Bronzing artefact from conjugated
Indications for exchange transfusion
- Rh disease, no transfusion in utero
- Cord blood Hb 80 umol/L
- Visible jaundice 340 and + and due to hemolysis
- Preterm or sick may need at lower BR
Risks of exchange transfusion
- Apnea
- BradyC
- Cyanosis
- Vasospasm
- Air embolism
- Infection
- Thrombosis
- Necrotising enterocolitis
- Rarely death
Monitoring following exchange transfusion
- Monitor Hb
- May need top up transfusion
- Assess for complication
