Jaundice in the neonatal period Flashcards Preview

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Flashcards in Jaundice in the neonatal period Deck (40):
1

Causes of unconjugated hyperbilirubinemia

1) Hemolytic
a) Intrinsic
-Membrane: spherocytosis, elliptocytsis
-Enzyme:G6PD, PK deficiency
-Hb: thalassemia
b) Extrinsic
-ABO, Rh incompatibility
-Splenomegaly
-Sepsis
-AV malformation

2) Non-hemolytic
-Hematoma
-Polycythemia
-Sepsis
-Hypothyroidism
-Gilbert
-Crigler-Najjar

3) Physiologic

2

Causes of conjugated hyperbilirubinemia

1) Hepatic
a) Infectious- Hep A, B, C, Sepsis, TORCH
b) Metabolic- Galactosemia, tyrosinemia, A1AT, Hypothyroid, CF
c) Drugs
d) TPN
e) Idiopathic neonatal hepatitis

2) Post hepatic
-Biliary atresia
-Choledochal cyst

3

Important history

Baby unwell- sepsis? bowel obstruction?
Dehydration, poor weight gain- can exacerbate
serology, viral
FHx of hemolysis
Dark urine, pale stools
Plethora
Hepatosplenomegaly->metabolic, viral

4

Investigations in unwell child/febrile

Septic screen
FBE/CRP/BC
UEC/LFT/VBG/Glucose
IV antibiotics
Bilirubin
Blood film/Reticulocytes
Blood group/Coombs

5

Investigations in well, afebrile

FBE
Bilirubin
Blood film/Reticulocytes
Blood group/Coombs

6

Investigations if conjugated bilirubin >15%

LFTs
Clotting
TFTs
Septic screen
Viral serology
A1AT levels
Abdominal USS
DW gastroenterology

7

Investigations when evidence of hemolysis

DW haematologist

8

Investigations when total in treatable range

NNU consultations
Urine MCS/reducible
UEC
G6PD
TFTs

9

Investigations when prolonged, and what is considered prolonged w/o an obvious cause

Prolonged is >2 weeks in full term and >3 weeks in preterm
DW paediatric senior
Urine MCS/reducing substrates
TFTs
G6PD
Arrange follow up

10

What are reducing substances

Galactose
Fructose
Glucose

11

Glycosuria -ve, but + urine for reducing substances, management

Further testing required
Remove lactose immediately from diet, pending results of further investigations

12

Discharge instructions for unconjugated hyperbilirubinemia

Sunlight is not treatment
Early F/U with GP
Ensure adequate oral intakes, especially

13

Phototherapy- hydration, monitoring, rechecking bilirubin

++Attention to fluid intake and hydration
Correct hydration over at least 24 hours
Check bilirubin after 6 hours starting therapy

14

What level of bilirubin rise should warrant call to NNU

If rate of rise >10micromol/L/hour

15

Final option for treatment if supportive and phototherapy no longer appropriate

Exchange transfusion

16

Important examination

Extent of the jaundice
Congenital viral infection->petechiae, anemia, hepatosplenomegaly
Dehydration
Well
Evidence of infection
Examine the stool

17

Why is checking clotting and vitamin K levels important

Prolonged jaundice can +risk of bleeding disorders associated with vitamin K deficiency

18

Wavelength of phototherapy

450nm

19

Commonest cause of jaundice in an older child

Hepatitis A

20

Other causes of jaundice in older children

Chronic hemolysis->spherocytosis, G6PD
Autoimmune chronic hepatitis
Reyes syndrome
Paracetamol overdose
Wilson's
Gilberts
Cigglar-Najar

21

When does physiological jaundice occur, and when does it resolve

Occurs on day 2-3, usually resolves in 7 days

22

Pathophysiology of physiological jaundice (3)

1) +Hct and reduced RBC lifespan
2) Immature conjugating system
3) Increased enterohepatic circulation

23

Risk factors for jaundice: maternal, perinatal, neonatal

Maternal:
Ethnic group
Complications->diabetes
Rh/ABO incompatibility

Perinatal:
Birth trauma
Prematurity

Neonatal factors:
Difficulty establishing breathing
Infection
Genetics
Polycythemia
Drugs

24

Causes of jaundice

25

Causes of jaundice 24-72

24-72 h
Physiologic, polycythemia
Dehydration
(breastfeeding jaundice)
Hemolysis
G6PD deficiency
Pyruvate kinase deficiency
Spherocytosis
Bruising, hemorrhage,
hematoma
Sepsis/congenital infection

26

Causes of jaundice 72-96

72-96 h
Physiologic ± breastfeeding
Sepsis
Prolonged
Breast milk jaundice

27

Causes of prolonged

Breast milk jaundice
Prolonged physiologic
jaundice in preterm
Hypothyroidism
Neonatal hepatitis
Conjugation dysfunction
e.g. Gilbert syndrome,
Crigler-Najjar syndrome
Inborn errors of metabolism
e.g. galactosemia
Biliary tract obstruction
e.g. biliary atresia

28

Differentiate breastfeeding jaundice vs breast milk jaundice

Breastfeeding jaundice if when reduced breast milk production->dehydration->exagerated physiologic jaundice

Breast milk jaundice: glucuronyl transferase inhibitor found in breast milK, onset day 7, persists for several weeks and resolves by 6 weeks. If not reason to cease breastfeeding

29

Red flags for pathalogical

1-2 weeks of age

30

Hemolytic work up

CBC
Reticulocyte
Blood group
Blood smear
Coombs test
Bilirubin

31

How does phototherapy work

Insoluble unconjugated bilirubin is converted to excretable form via photoisomerisation

32

Can you perform phototherapy in conjugated hyperbilirubinemia, why

No
Results in bronzed baby

33

Etiology of kernicterus

Unconjugated bilirubin levels ++ than binding capacity of albumin->deposit in brain stem and basal ganglia

34

What level of bilirubin= risk of kernicterus

When levels >340umol/L

35

When can kernicterus occur at lower levels than

sepsis, meningitis, hemolysis, hypoxia, acidosis,
hypothermia, hypoglycemia and prematurity

36

Clinical presentations: early (4), mid (6), late stage (6)

Early: hypotonia, lethargic, poor feeding, emesis
Mid: hypertonic, high pitched cry, opisthotonic posturing (back archign), bulging fontanelles, seizures and pulmonary hemorrhage.
Late (beyond a year): hypotonia, EPS (choreoathetoid cerebral palsy), gaze palsy, mitral regurgitation, sensorineural hearing loss.

37

Long term complications of kernicterus

Sensorineural deafness
Choreoathetoid cerebral palsy
Gaze palsy
Mental retardation

38

What is biliary atresia and how does it present

Atresia of extrahepatic bile ducts->cholestasis, +conjugated bilirubin
Dark urine, pale stool
Jaundice persisting for >2 weeks
Abdominal distension
hepatomegaly

39

Diagnosis of biliary atresia- investigations

Conjugated hyperbilirubinemia, abdominal USS
HIDA san
Liver biopsy

40

Treatment of biliary atresia

• surgical drainage procedure
• hepatoportoenterostomy (Kasai procedure; most successful if

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