peds jaundice Flashcards
bilirubin labs
get total and direct
TSB (total serum bilirubin)
TcB (total capillary bilirubin)
STANDARD ON ALL BABIES AT 24 HRS
what can cause neonatal jaundice
lack of intestinal flora
meconium in ileus
pathway
RBC–>ingested by macrophage–>hemoglobin broken down to–>heme and globin–>heme broken down (heme oxygenate) to iron and protoporphyrin–>bilirubin (toxic!, yellow)–>conjugated to albumin–>carried to liver–>conjugated by UGT–>conjugated is water-soluble–>”pooped and peed out” (or recycled via enterohepatic circulation)
babies lack UGT and have
slow digestion
if bilirubin deposited in basal ganglia
kernicterus
babies also have ?? that hydrolyzes back into unconjugated form
Beta-glucuronidase (intestinal enzyme)
Neonates have excessive Beta-glucuronidase and low intestinal flora
why do you want total and direct??
determine if before hepatic or hepatic problem
at 24 hrs if Hgb is ?? it is worrisome
5 or greater
tx that can reduce hyperbilirubemia
phototherapy, blue lights
FA: phototherapy converts unconjugated bilirubin to water-soluble form (will not work for conjugated, direct bilirubin)
Term infant. Born via c section for failure to progress. Mom’s blood type is A+. Infant is A+ coombs negative. Mom is breastfeeding.
At 24 hours, infant is jaundiced
consider dehydration, just a little bit of colostrum
- slow gut, reabsorbing bilirubin
- C-section, not as much trauma
- asian races more hyperbili, harder to see on darker skin
- also worry about infection, (chorio/congenital infection)
- physiologic jaundice assoc. w. breastfeeding; Uncon.hyperbili that occurs after the first postnatal day and can last up to 1 week.
- 3-5 pk for normal Hgb
- 5-7 for premies
- more than 15 not physiologic
physiologic jaundice: Bilirubin production is increased as a result of ?? per body weight and a ??
Infants also have immature ??
elevated hematocrit and red blood cell volume
shorter life span of the red blood cells.
hepatic glucuronyl transferase (UDP-GT).
Breast milk jaundice is different
present week or 2 later, something in mom’s milk
helps to stop for a day or so “reset”
Elevated indirect (unconjugated)
Dehydration
Breastfeeding
Hemolytic processes
Difficulty conjugating
Elevated direct (conjugated)
Liver obstruction
Hepatocyte dysfunction
Metabolic injury to liver
Infectious liver injury (ToRCH
Cephalohematoma
does not cross suture lines, significant bruising (vs papits?)
Rh and ABO incompatibility
- ABO and Rh (D) blood T/S for other isoimmune antibodies should be evaluated in all pregs
- if not done or mom is O or Rh-negative, the infant’s cord blood should be evaluated for a direct antibody (Coombs) test, blood type, and Rh determination.
- Mother-infant ABO incompatibility (more common than Rh- typically given Rhogam) occurs in approximately 15% of all pregnancies, but symptomatic hemolytic disease occurs in only 5% of these infants.
O- NO (mom’s blood)
- babies get blood type and direct COOMBs
- Jaundice from ABO hemolytic disease usually is detected within the first 12 to 24 hours after birth.
- get cord bilirubin, if high, keep checking every 6-8 hrs, may start phototx even before curve
- reticulocyte will be elevated
Hemolytic anemia caused by isoantibodies in the infant is a major risk factor for severe hyperbilirubinemia and bilirubin neurotoxicity.
O-NO
Testing for “foreign”antibodies with Direct Coombs Test
only for Abs, not for G6PD, hereditary spherocytosis (can also result in severe hyperbilirubinemia)
-positive Coombs’ test in the lab does not necessarily result in hyperbilirubinemia in the infant; Active hemolysis may be present with a negative Coombs’ test.
G6PD deficiency
more common in the populations around the Mediterranean and in the Middle East, Arabian peninsula, SE Asia, and Africa, 11% to 13% of African Americans
- need to measure, not part of neonatal screen, order when not responding to phototx or suspect due to origin
- cause of hyperbilirubinemia in 19 of 61 (31.5%) infants who developed kernicterus
You are called by the nurse about Baby Boy, a 18 hour old male that appears jaundice to the face and neck. What should you do?
Review baby chart and order labs as appropriate:
- total and direct bilirubin
- CBC
- COOMBs
- blood type of baby and mom
- evaluate for sepsis
For any infants who develop jaundice in the first 24 hours after birth a ??should be assessed.
TcB (transcutaneous) or TSB (total serum)
-Once a bilirubin has been measured, the result should be interpreted based on the bilirubin nomogram.
Nomogram is based on infants greater than 35 weeks’ gestation who have no evidence of hemolytic disease.
hyperbilirubinemia risk factors
Isoimmune hemolytic anemia G 6-P-D Deficiency Asphyxia Temperature instability Sepsis Acidosis Significant lethargy Albumin
bilitool
use to assess if need phototx
When do we have to investigate the cause of jaundice?
Evaluation is appropriate for any infant who is receiving phototherapy or when the TSB crosses percentiles on the nomogram.
Cause is not evident after a thorough history assessing risk factors.
Significant hyperbilirubinemia occurred in siblings.
jaundice eval Begins with taking a ??
good history and a thorough physical exam
- Infant gestation – both by dates and physical exam
- Maternal and baby blood type and antibody testing
- Physical exam findings of bruising or cephalohematoma
- Cranio-caudal progression of jaundice?
jaundice gradient: Hgb concentrations
eyes: about 4
face: 6
upper chest/neck: 8
abdomen: 10
hips: 12
thighs: 14-15
toes: close to 20
-quick assessment, not as accurate as blood work
-also check cap refill, esp. in darker skin
Term infant. Born via normal spontaneous vaginal delivery. Mom without prenatal care, first infant.
Minimal bruising on head.
At 18 hours, infant is noted to be jaundiced
Total Bilirubin total level is 12
Direct Bilirubin is 0.2
12 is on the graph (18 hrs)
-if direct 2.0 or higher is significant for direct hyperbilirubinemia
basic labs
Bilirubin Total
Bilirubin Direct
(consider checking every 4-12 hours depending on rate of rise)
additional labs (if abnormal increase)
CBC with reticulocyte count TSH G6PD Blood type and coombs Other *blood cultures *evaluate for inborn errors of metabolism Bilirubin/albumin ratio
Maternal Blood type is O+ Infant Blood type is B+, COOMBs + Reticulocyte count is 14 (high) Hemoglobin is 17 (normal?) assessment?
hemorrhagic/hemolytic, due to ABO incompatability
tx would be
phototx, hydrations, check bilirubin every 8-12 hours
Pathologic Jaundice
increased bili production
impaired bili conjugation
decreased bili excretion
other/combo
conjugated hyperbilirubinemia
defined by a conjugated bili concentration greater than 1 mg/dL when the TSB concentration is 5 mg/dL or less.
-If the TSB concentration is greater than 5 mg/dL, conjugated hyperbili is defined when the value is 20% or greater of the TSB concentration.
conjugated hyperbilirubinemia: Decreased Bilirubin Excretion
Biliary obstruction Biliary atresia Choledochal cyst Dubin-Johnson syndrome Rotor syndrome
what hx to ask mom??
baby vomiting, do sibling have/had this condition
are the stools pale
-also check for hepatomegaly:
biliary atresia
biliary atresia typical presentation
A 4-day-old male: direct hyperbilirubinemia.
- breastfeeding fine, was urinating well, and had stools that were pale-colored.
- hepatomegaly
- catch before a month, better for sx intervention
Choledocal cyst typical presentation
- first months of life
- 80% of patients have cholestatic jaundice and acholic stools
- Vomiting, irritability, and failure to thrive may occur
- Physical examination shows hepatomegaly and, in approximately one half of patients, a palpable abdominal mass
- dx best with Ultrasound
elevated conjugated/direct: other causes
problem in liver galactosemia TORCH infections: hepatomegaly congenital hepatitis (A,B,C) Dubin Johnson and Rotor’s Syndromes CMV
every time direct is over 2, (or greater than 20% total) considered??
direct hyperbilirubinemia
what to do??
Term infant who is now 6 days old. Mom is concerned because she is jaundiced. Total bilirubin is 12 Direct Bilirubin is 5 what is it considered?? what to do??
direct hyperbilirubinemia
U/S of liver check for hepatitis A,B,C neonatal inborn error of metabolism: check for galactesemia, hypothyroidism TORCH infections: Abs for CMV, etc. also consider CF
Which of these involve a problem of bilirubin excretion? Crigler-Najjar Gilbert Syndrome Dubin-Johnson Syndrome Breast Milk Jaundice None of the above
Dubin-Johnson (direct)
do we use phototherapy for conjugated??
tx??
NO, will not help, will actually make bronze
ID the cause, tx will vary
neurodevelopment with indirect bilirubinemia (NOT with direct)
kernicterus can cause athetoid cerebral palsy: writhing, look like in pain
-deposits in basal ganglion
mom is O- and did not get Rhogam (sensitized), 2nd baby who is Rh+ can have ??
- marked elevated Coombs+
- fetal problems, hemolysis in utero
- born jaundice with high indirect levels
- if can’t control with phototherapy, can do blood exchange (transfusion, takes about 2 hrs, central lines, pull a few mLs out, push a few in, monitor vitals)-“latch-ditch” effort
- do to prevent kernicterus
- so many Abs from mom causing hemolysis
