Neonatal jaundice

Question 1

Etiology

Answer 1

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

2. 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

Question 2

When is jaundice visible

Answer 2

1. When levels 85-120umol/L

Question 3

When is jaundice more severe/prolonged

Answer 3

1. Prematurity
2. Acidosis
3. Hypoalbuminemia
4. Dehydration

Question 4

How common is jaundice

Answer 4

1. 60% of term infants develop jaundice

Question 5

Onset and progression of physiologic jaundice, pathophysiology

Answer 5

1. Onset at day 2-3 of life, resolution by day 7
2. PathoP
   +RBC number and shortened lifestyle
   Immature glocorynyl transferase->poor conjugation
   +Enterohepatic circulation
   Decreased uptake and binding by liver cells

Question 6

Breastfeeding jaundice

Answer 6

1. Due to lack of milk supply->dehydration->more exagerated physiologic jaundice

Question 7

Breastmilk jaundice, cause, progress

Answer 7

1. 1 per 200 infants
2. Glocorinyl transferase inhibitor in the milk
3. Onset day 7 of life->peaks at 2-3 weeks and resolves by 6 weeks.

Question 8

When should pathologic jaundice be considered

Answer 8

1. When

Question 9

Risk factors

Answer 9

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

Question 10

Initial assessment of all babies with jaundice

Answer 10

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

Question 11

If

Answer 11

Medical emergency

1. Measure and record serum bilirubin within 2 hours
2. Manage as per treatment graphs
3. Neonatalogy/pediatrician review within 6 hours
4. Commence phototherapy whilst awaiting results
5. Do investigations
6. Manage fluids

Question 12

24 hours to 10 days

Answer 12

1. Measure and record TcB or serum bilirubin w/i 6 hours
2. Manage as per treatment line
3. Commence phototherapy if >6 hours for results, baby has risk factors, TCB >250mmol/L or above treatment threshold, jaundice below the nipple
4. Medical review required
5. DO investigations if cause not obvious
6. Manage fluids
7. Be sure to treat underlying sepsis
8. Arrange F/U with midwife/GP to ensure adequate oral intake
   2 weeks for term, >3 weeks for preterm

Question 13

Prolonged jaundice management

Answer 13

1. Usually breastfeeding related
2. Investgate
   Total and conjugated bilirubin
   FBC + film
   Reticulocyte count
   Blood group
   DAT
   TFTs
   Review NBST
3. Seek expert advice if +conjugated, dark urine and pale stools
4. Fluid management
5. Consider additional investigations

Question 14

Signs of acute bilirubin encephalopathy

Answer 14

1. Bilirubin toxicity in first few weeks of life
2. Lethargic
3. Irritable, temperature instability, opisthotonos, spasticity
4. Apnea
5. Hypotonia, poor sucking reflex->hypertonic, high pitched cry, seizures and coma

Question 15

Definition and manifestations of chronic bilirubin encephalopathy

Answer 15

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

Question 16

Define kernicterus

Answer 16

1. Yellow staining of basal ganglia

2. Frequently used to refer to the clinical sequelae

Question 17

When is kasai procedure best done

Answer 17

1. Before 45-60 days of life

Question 18

Prevention of jaundice

Answer 18

1. Early and frequent breastfeeding
2. Blood group, Rh, Coombs test on cord blood if mothers blood group is negative or unknown
3. Risk assessment before d/c and plan f/u
4. Monitor all infants for jaundice 12 horly

Question 19

What is Kramer’s rule

Answer 19

1. The level of jaundice on infant->face->trunk->arms and legs can crudely correspond to serum bilirubin level

Question 20

Infants at higher, medium and lower risk

Answer 20

1. Higher
35-37 + risk factors
2. Medium
38 + risk factors
3. Low
38 + well

Question 21

Brief overview Mx

Answer 21

1. Fluids
2. Phototherapy
3. Exchange transfusion
4. IV immunoglobulin if hemolytic and not responding

Question 22

How does phototherapy work

Answer 22

1. Exposure to light photoisomerises unconjugated bilirubin->+solubility->can then be excreted in feces and urine
2. Blue light is best 460-490nm

Question 23

How to increase effectiveness of phototherapy

Answer 23

1. +amount of skin exposed
2. +intensity of the light
3. Additional overhead light
4. Closer light to baby

Question 24

Biliblanket

Answer 24

1. Outpatient

2. Allows therapy in open cot with mum on ward

Question 25

Monitoring phototherapy and cessation

Answer 25

1. Adequacy hydration and nutrition, continue breastfeeding 2. Temperature 3. Clinical improvement 4. Potential signs of bilirubin encephalopathy 5. Cease when SBR

Question 26

Potential complications of phototherapy

Answer 26

1. Overheat 2. Water loss, diarrhea->hydration 3. Rash 4. Parental anxiety/separation->educate and reassure 5. Ileus->bowel motions, distention 6. ?Retinal damage 7. Bronzing artefact from conjugated

Question 27

Indications for exchange transfusion

Answer 27

1. Rh disease, no transfusion in utero 2. Cord blood Hb 80 umol/L 4. Visible jaundice 340 and + and due to hemolysis 6. Preterm or sick may need at lower BR

Question 28

Risks of exchange transfusion

Answer 28

1. Apnea 2. BradyC 3. Cyanosis 4. Vasospasm 5. Air embolism 6. Infection 7. Thrombosis 8. Necrotising enterocolitis 9. Rarely death

Question 29

Monitoring following exchange transfusion

Answer 29

1. Monitor Hb 2. May need top up transfusion 3. Assess for complication