Flashcards in Neonatal Jaundice Deck (18)
What are the types of neonatal jaundice?
Physiological - unconjugated
Pathological - unconjugated/conjugated
What is physiological jaundice due to?
Increased bilirubin production in neonates due to shorter RBC lifespan - high concentration of Hb breaks down releasing
Decreased bilirubin conjugation due to hepatic immaturity
Absence of gut flora impedes elimination of bile pigment
Exclusive breastfeeding (esp. if there are feeding difficulties -> reduced intake -> dehydration -> reduced bilirubin elimination -> increased enterohepatic circulation of bilirubin
Describe the course of physiological jaundice
Starts at day 2-3, peaks at day 5, usually resolved by day 10
Can progress to pathological jaundice if baby is premature or there is increased red cell breakdown
What can pathological jaundice be due to?
Rhesus, ABO incompatibility, Red cell anomalies Congenital spherocytosis, G6PD-deficiency
Metabolic: hypothyroid, galactosaemia
Breast milk jaundice
GI: biliary atresia
What is prolonged jaundice? What can cause this?
Jaundice for over 14 days or 21 days in poems
Biliary atresia if conjugated and pale stools
What are risk factors for pathological jaundice
Low birth weight
Small for dates
Previous sibling requiring phototherapy
Exclusively breast fed
Jaundice < 24 hours
What are clinical features of hyperbilirubinaemia?
Drowsy - difficult to rouse, not waking for feeds, very short feeds
Neurologically - altered muscle tone, seizures - require immediate attention
Other: signs of infection, poor urine output, abdominal mass
What investigations in neonatal jaundice?
Serum bilirubin if:
<35/40, <24hours old, or transcutaneous bilirubin >250micromol/L
Maternal blood group, baby blood group
Direct Coomb's test for Rh haemolytic disease
FBC for haemoglobin and haematocrit
with blood film
U&E if excessive weight loss/dehydrated
Infection screen if unwell or < 24 hours
LFT if hepatobiliary disorder
What is management for neonatal jaundice?
Refer to treatment threshold graph for neonatal jaundice
Phototherapy if above or on phototherapy line for their gestation and age in days
Exchange transfusion via umbilical artery or vein if on or above threshold line.
IV immunoglobulin can be used as adjunct to intensified phototherapy in Rh disease/ABO incompatibility.
What if neonate is below phototherapy threshold?
How often should bilirubin be monitored during treatment?
When should phototherapy be stopped?
If <50micromol/L below line, repeat level within 18 hours (if risk factors) to 24 hours (no risk factors)
Ultraviolet isomerisation of bilirubin to its soluble for for excretion
During photo therapy:
Repeat bilirubin 4-6 hours post initiation to ensure no still rising, 6-12 hourly once level is stable or reducing
Stop phototherapy once level is >50micromol/L below treatment threshold
Check for rebound hyperbilirubinaemia 12-18h after stopping
What is exchange transfusion?
Simultaneous exchange of baby's blood with donated blood or plasma to prevent further bilirubin increase and decrease serum bilirubin levels.
Given ideally via umbilical vein IVI and removed via umbilical artery
Usually done when there are signs of acute bilirubin encephalopathy
What is kernicterus?
Acute bilirubin encephalopathy
Chronic bilirubin encephalopathy
Yellow staining in the brain
Accumulation of bilirubin in the CNS grey matter causing irreversible neurological damage
Long term sequelae - athetoid movements, deafness, and low IQ
Prevented by phototherapy ± exchange transfusion
Describe Rhesus haemolytic disease
When RhD-ve mother delivers RhD+ve baby, leak of fetal red cells into her circulation may stimulate her to produce anti-D IgG antibodies.
In subsequent pregnancies these can cross the placenta causing worsening Rh haemolytic disease in Rh+ve pregnancies
First pregnancies may be affected due to leaks - threatened miscarriage, APH, Mild trauma, amniocentesis, chorionic villous sampling
What are signs of Rh disease
Jaundice on day 1
Yellow vernix (greasy covering of baby)
CCF (oedema, ascites)
How is Rh disease managed?
Test for D antibodies in all Rh-ve mothers
Phototherapy (isomerisation of bilirubin to its soluble form)
Give extra water
Avoid heat loss
Protect the eyes
Keep baby naked
Keep breastfeeds short to maximise time under lights
Keep baby warm
What is hydrops fetalis?
Severely affected oedematous fetus with stiff oedematous lungs is called a hydrops fetalis.
Anaemia associated CCF causes oedema as does hypoalbuminaemia (liver is preoccupied by producing new RBCs)
Mx of hydrops fetalis?
take cord blood for Hb, PCV, bilirubin (conjugated and unconjugated), blood group, Coombs, serum protein, LFT and infection screen to find cause
- isoimmunisation, thalassaemia, infection, toxoplasmosis, syphilis, parvoviruses, maternal diabetes, hypoproteinaemia
Expect need to ventilate with high inspiratory peak pressure and positive end pressure
Monitor plasma glucose 2-4 hourly, treating any hypoglycaemia
Drain ascites, pleural effusions
Vitamin K to reduce risk of haemorrhage
Furosemide if CCF is present
Limit IV fluids