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Pediatrics > CLIPP case 8. Newborn (jaundice, feeding, stools, supplements) > Flashcards

CLIPP case 8. Newborn (jaundice, feeding, stools, supplements) Flashcards

1
Q

Newborn bilirubin physiology

A

Breakdown of RBCs -> unconjugated bilirubin binds to albumin -> (low levels of) uridine diphosphate gucuronosyl transferase -> conjugated bilirubin -> excreted into bile -> (in adults metabolized by flora to urobilinogen then stercobilinogen and excreted in stool) -> Neonatal lack of GI flora, so beta-glucuronidase of meconium hydrolyzes it back to unconjugated form -> reabsorption into blood stream and binding to albumin (this is enterohepatic circulation)

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2
Q

Kernicterus

A
  • Basal ganglia and cranial nerve nuclei stained by bilirubin -> loss of suck reflex, lethargy, irritability, seizures, death
  • Survivors: opisthotonus, rigidity, oculomotor paralysis, tremors, hearing loss, ataxia
  • In past was most common in Rh incompatibility (erythroblastosis fetalis) with Tbili > 25
  • Decreased now due to: screening for Rh and tx with RhoGAM; tx of unconjugated hyperbili with phototx
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3
Q

Opisthotonus

A

In survivors of kernicterus: abnormal posturing with rigidity and sever arching of back with head thrown backward

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4
Q

Etiologies of jaundice

A

1) Physiologic
2) Breast milk jaundice
3) Hemolysis: ABO or Rh incompatibility (positive direct Coombs or direct antibody test DAT), or antibody negative hemolysis (spherocytosis, G6PD def, pyruvate kinase def)
3) Non-hemolytic RBC breakdown: birth trauma, cephalohematoma, ICH, polycythemia, swallowed blood if large amount
4) Sepsis infection
5) Liver: biliary atresia, hepatitis
6) Metabolic: hypothyroidism, hypoglycemia, galactosemia, urea cycle defect, Crigler-Najjar (UDPGT def), Gilbert’s (UDPGT low)

*SCD and thalassemia do not cause jaundice

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5
Q

Physiologic jaundice

A
  • Due to increased enterohepatic circulation: increased RBC breakdown, low UDP glucuronosyl transferase, low GI flora, high Beta-glucuronidase in meconium, and small oral intake to push meconium through (especially breastfed infants)
  • Total bilirubin ≤15 mg/dL in otherwise healthy full term infants, no tx required
  • Almost all newborns have hyperbilirubinemia, peak level at day 3-4, resolves by day 5
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6
Q

Jaundice associated with breastfeeding

A
  1. Breastfeeding: Low intake in first week causing retention of meconium and increased enterohepatic circulation
  2. Breastmilk: Beta-glucuronidase in milk (as in meconium) deconjugates bilirubin and increases enterohepatic circulation. Can last 12 weeks, but rarely reaches concerning levels
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7
Q

Successful breastfeeding

A

8-12 x per day. Initially last long 60 min, but then 10-15 min at each breast. Longer feeds may indicate a problem

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8
Q

Breastmilk

A

Perfect balance of carbs, lipids (50%), proteins (whey and casein), as well as antibodies, growth factors, etc.

*Most of the fat appears at the end of feeding, so is important to empty each breast

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9
Q

Breastfeeding advantages

A

Bonding, lower infection, lower SIDS, lower allergies

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10
Q

Healthy appearing infant with jaundice, dark urine, and pale (acholic) stools at 3-6 weeks

A

Biliary atresia -> Kasai procedure

*Usually presents later, after 2 weeks

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11
Q

Major risk factors for harmful hyperbilirubinemia

A

*Pre-discharge total bili or total conjugatic bili in “high-risk” zone, jaundice in first 24hr life, blood group incompatibility with +DAT, gestational age 35-36 wk, previous sibling with phototx, cephalohematoma/significant bruising, exclusive breastfeeding if not going well and excess wt loss, East Asian race

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12
Q

Tyenol and codeine in breastfeeding

A

No. Codeine can metabolize to morphine

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13
Q

Supplements for infants

A
  • Vitamin D (440 IU daily) for all breastfed infants to prevent rickets.
  • Iron fortified cereals and meats at 6 months
  • Fluoride at 6 months if water supply lacks
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14
Q

Non-hemolysis breakdown of RBCs causing jaundice

A

1) Head trauma:
- Bruising from birth trauma
-Cephalohematoma (subperiosteal hemorrhage that does NOT cross suture lines) or ICH
(Caput succedaneum (edematous swelling over scalp, overlying periosteum, that crosses suture lines) would not cause hyperbilirubinemia)

2) Polycythemia
3) Swallowed blood during delivery

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15
Q

Risk factors for developmental dysplasia of the hip

A
  • Lef hip 3:1. Can appear later than at birth
  • Girls
  • Breech
  • Caucasian, Native American
  • Family hx
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16
Q

DDH screening

A

*Girls born via breech, in Left hip 3:1, white or Native, family history

  • Barlow: dislocatable hips
  • Ortolani: dislocated hips

*U/S at 4-6 weeks or a hip/pelvis radiograph at 4 months

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17
Q

Jaundice in infection

A
  • RARELY the only sign (usually other symptoms, like fever, instability, respiratory distress, apnea, lethargy, irritability, poor tone, vomiting, poor feeding)
  • Direct bilirubin!
18
Q

Neonatal screening

A

Optimal time is ≥24 hours after birth (otherwsie PKU and other disorders could be missed). If obtained prior to 24 hour, second specimen should be obtained in next 1-2 weeks.

19
Q

Newborn with prolonged jaundice, lethargy, large fontanelles, macroglossia, umbilical hernia, constipation, distention, developmental retardation

A

Hypothyroidism

20
Q

Bhutani nomogram

A
  • Assesses risk level based on Tbili and age

* Used to determine when to implement phototherapy

21
Q

Infant with breastmilk jaundice and Tbili 17, but no other risk factors

A
  • Continue breastfeeding and recheck tbili in 24 hours. Jaundice may persist for 12 weeks. If continues at 2 weeks, check total and direct levels (and check dark urine or acholic stools to r/o cholestasis development).
  • Temporary break from breastfeeding is considered when tbili 16-25 range, but provides no long-term benefit
  • Phototx if rapid reduction of tbili is needed
22
Q

Increasing direct bilirubin in an infant

A

Biliary atresia? Alpha-1 antitrypsin deficiency? Infection?

23
Q

% of newborns to develop jaundice in the U.S.

A

60%

24
Q

6 day-old girl is jaundiced, but otherwise
appears healthy. Time frame and total bilirubin > 15 mg/dL suggests the jaundice is not physiological. Positive family history of Mediterranean origin (G6PD deficiency). Normal NBS rules out metabolic and hypothyroid. Normal CBC rules out
hemolytic disease. History of breastfeeding, normal physical exam, and later appearance of jaundice support breastfeeding-associated jaundice.

A

Breastfeeding-associated jaundice: continue breastfeeding and observe

25
Q

Hemolysis jaundice

A

1) Antibody-positive = Direct Coombs or direct antibody test (DAT) positive
- Rh incompatibility
- ABO incompatibility
- Incompatibilities with minor blood group antigens

2) Antibody-negative = Direct Coombs or DAT negative
- RBC membrane defects (spherocytosis,
elliptocytosis)
- Enzyme defects (G6PD or pyruvate kinase
deficiency)

26
Q

Inborn metabolic disorders causing jaundice

A

1) Crigler-Najjar syndrome: Decreased bilirubin clearance caused by completely absent UDPGT, or deficient (Gilbert’s)
2) Galactosemia
3) Hypothyroidism

27
Q

Risk factors for jaundice

A
  • Asian > white > black
  • Mediterranean (X-linked G6PD deficiency -> hemolysis
  • Family history of anemia or jaundice
  • Prematurity
  • Bowel obstruction
  • Birth at high altitude
28
Q

Colostrum

A
  • Yellowish fluid produced in the first five days postpartum, gradually replaced by milk
  • Concentrated source of non-nutritive substances: oligosaccharides, lactoferrin, lysozyme, growth factors, bifidobacteria, and others that protect against infection and promote growth
29
Q

Breastfeeding problems

A
  • Enlarged, tender breasts (commonly caused by engorgement, mastitis, plugged ducts [galactocele])
  • Improper latch, suckle
  • Prolonged feedings
  • Infants fall asleep before they finish feeding
  • Maternal inexperience/anxiety
30
Q

Normal newborn elimination

A
  • Stools: Day 3 yellow (no longer meconium). Day 7, ≥3 stools/day
  • Urine: Day 3, ≥3 times a day. Day 6, ≥6 times a day. Urine should be pale yellow.
31
Q

Newborn weight loss

A

*Breastfed infants may lose up to 10% of their birth weight during first week, and should return to birth weight by 2 weeks.

32
Q

Newborn head findings

A
  • Fontanelle: Initially anterior fontanelle may barely be open due to overriding sutures. Within a few days, sutures separate. Average diameter of anterior fontanelle 2.5–5.0 cm. In most full-term newborns the posterior fontanelle is not palpable.
  • Caput succedaneum: Edematous swelling over the presenting portion of the scalp of an infant. It overlies the periosteum and crosses suture lines.

*Cephalohematoma: Subperiosteal hemorrhage. Does not extend across a
suture line. Can cause jaundice.

33
Q

Newborn breast tissue

A
  • Normal: 0.5–1.0 cm of palpable breast tissue, uni or bilateral, male or female
  • Distinguish from mastitis, in which breast has redness, warmth and swelling
34
Q

Newborn abdomen exam

A
  • HSM in jaundiced newborn: galactosemia, significant hemolytic disease, congenital infections (CMV, toxoplasmosis, syphilis, rubella, herpes)
35
Q

Liver disease jaundice

A

1) Biliary atresia: typically present at 3-6 weeks, with progressive jaundice, dark urine, acholic stools. Direct bilirubin. Kasai procedure tx.
2) Intrinsic liver disease: Very rare cause. Gilbert’s syndrome (reduced UDPGT) is
relatively common cause of harmless jaundice (seen in approximately 5% of the population).
Crigler-Najjar syndrome (absence or low UDPGT) can cause severe (type I) or mild (type 2) jaundice.

36
Q

Bad signs of jaundice

A
  • If < 24 hours of age or significant

* TBili > 15 mg/dL

37
Q

Iron supplementation

A

-Infants who have been exclusively breastfed should be should be started on iron-enriched foods, such as fortified cereals and meats, at six months

38
Q

Fluoride supplementation

A

-If water supply lacks fluoride, breastfed and bottle-fed infants should both receive fluoride supplements after six months of age

39
Q

Vitamin D supplementation

A

-Exclusively breastfed infants may need vitamin D supplementation in the first six months. Supplementation with 400 IU of vitamin D should be initiated within days of birth for all breastfed infants.
-(Infants who are not breastfed should
also receive supplementation with 400 IU of vitamin D if they do not ingest at least 1 L of vitamin D-fortified formula daily.)
*Rickets can occur in strictly breastfed infants (generally appears 6-24 months and responds to treatment with vitamin D).

40
Q

Breast engorgement from breastfeeding

A
  • Instruct mother to apply warm compresses before breastfeeding and cold compresses between feedings to relieve the discomfort
  • Use manual or mechanical expression of the areola to relieve fullness and facilitate latching-on
  • Have baby nurse frequently to relieve breast engorgement

Pediatrics (20 decks)

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