peds jaundice

Question 1

bilirubin labs

Answer 1

get total and direct
TSB (total serum bilirubin)
TcB (total capillary bilirubin)
STANDARD ON ALL BABIES AT 24 HRS

Question 2

what can cause neonatal jaundice

Answer 2

lack of intestinal flora

meconium in ileus

Question 3

pathway

Answer 3

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)

Question 4

babies lack UGT and have

Answer 4

slow digestion

Question 5

if bilirubin deposited in basal ganglia

Answer 5

kernicterus

Question 6

babies also have ?? that hydrolyzes back into unconjugated form

Answer 6

Beta-glucuronidase (intestinal enzyme)

Neonates have excessive Beta-glucuronidase and low intestinal flora

Question 7

why do you want total and direct??

Answer 7

determine if before hepatic or hepatic problem

Question 8

at 24 hrs if Hgb is ?? it is worrisome

Answer 8

5 or greater

Question 9

tx that can reduce hyperbilirubemia

Answer 9

phototherapy, blue lights

FA: phototherapy converts unconjugated bilirubin to water-soluble form (will not work for conjugated, direct bilirubin)

Question 10

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

Answer 10

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

Question 11

physiologic jaundice: Bilirubin production is increased as a result of ?? per body weight and a ??

Infants also have immature ??

Answer 11

elevated hematocrit and red blood cell volume
shorter life span of the red blood cells.

hepatic glucuronyl transferase (UDP-GT).

Question 12

Breast milk jaundice is different

Answer 12

present week or 2 later, something in mom’s milk

helps to stop for a day or so “reset”

Question 13

Elevated indirect (unconjugated)

Answer 13

Dehydration
Breastfeeding
Hemolytic processes
Difficulty conjugating

Question 14

Elevated direct (conjugated)

Answer 14

Liver obstruction
Hepatocyte dysfunction
Metabolic injury to liver
Infectious liver injury (ToRCH

Question 15

Cephalohematoma

Answer 15

does not cross suture lines, significant bruising (vs papits?)

Question 16

Rh and ABO incompatibility

Answer 16

• 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.

Question 17

O- NO (mom’s blood)

Answer 17

• 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

Question 18

Hemolytic anemia caused by isoantibodies in the infant is a major risk factor for severe hyperbilirubinemia and bilirubin neurotoxicity.

Answer 18

O-NO

Question 19

Testing for “foreign”antibodies with Direct Coombs Test

Answer 19

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.

Question 20

G6PD deficiency

Answer 20

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

Question 21

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?

Answer 21

Review baby chart and order labs as appropriate:

• total and direct bilirubin
• CBC
• COOMBs
• blood type of baby and mom
• evaluate for sepsis

Question 22

For any infants who develop jaundice in the first 24 hours after birth a ??should be assessed.

Answer 22

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.

Question 23

hyperbilirubinemia risk factors

Answer 23

Isoimmune hemolytic anemia
G 6-P-D Deficiency
Asphyxia
Temperature instability 
Sepsis
Acidosis
Significant lethargy
Albumin

Question 24

bilitool

Answer 24

use to assess if need phototx

Question 25

When do we have to investigate the cause of jaundice?

Answer 25

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.

Question 26

jaundice eval Begins with taking a ??

Answer 26

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?

Question 27

jaundice gradient: Hgb concentrations

Answer 27

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

Question 28

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

Answer 28

12 is on the graph (18 hrs) | -if direct 2.0 or higher is significant for direct hyperbilirubinemia

Question 29

basic labs

Answer 29

Bilirubin Total Bilirubin Direct (consider checking every 4-12 hours depending on rate of rise)

Question 30

additional labs (if abnormal increase)

Answer 30

``` CBC with reticulocyte count TSH G6PD Blood type and coombs Other *blood cultures *evaluate for inborn errors of metabolism Bilirubin/albumin ratio ```

Question 31

``` Maternal Blood type is O+ Infant Blood type is B+, COOMBs + Reticulocyte count is 14 (high) Hemoglobin is 17 (normal?) assessment? ```

Answer 31

hemorrhagic/hemolytic, due to ABO incompatability

Question 32

tx would be

Answer 32

phototx, hydrations, check bilirubin every 8-12 hours

Question 33

Pathologic Jaundice

Answer 33

increased bili production impaired bili conjugation decreased bili excretion other/combo

Question 34

conjugated hyperbilirubinemia

Answer 34

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.

Question 35

conjugated hyperbilirubinemia: Decreased Bilirubin Excretion

Answer 35

``` Biliary obstruction Biliary atresia Choledochal cyst Dubin-Johnson syndrome Rotor syndrome ```

Question 36

what hx to ask mom??

Answer 36

baby vomiting, do sibling have/had this condition *are the stools pale* -also check for hepatomegaly: biliary atresia

Question 37

biliary atresia typical presentation

Answer 37

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

Question 38

Choledocal cyst typical presentation

Answer 38

- 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

Question 39

elevated conjugated/direct: other causes

Answer 39

``` problem in liver galactosemia TORCH infections: hepatomegaly congenital hepatitis (A,B,C) Dubin Johnson and Rotor’s Syndromes CMV ```

Question 40

every time direct is over 2, (or greater than 20% total) considered??

Answer 40

direct hyperbilirubinemia what to do??

Question 41

``` 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?? ```

Answer 41

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 ```

Question 42

``` Which of these involve a problem of bilirubin excretion? Crigler-Najjar Gilbert Syndrome Dubin-Johnson Syndrome Breast Milk Jaundice None of the above ```

Answer 42

Dubin-Johnson (direct)

Question 43

do we use phototherapy for conjugated?? | tx??

Answer 43

NO, will not help, will actually make bronze | ID the cause, tx will vary

Question 44

neurodevelopment with indirect bilirubinemia (NOT with direct)

Answer 44

kernicterus can cause athetoid cerebral palsy: writhing, look like in pain -deposits in basal ganglion

Question 45

mom is O- and did not get Rhogam (sensitized), 2nd baby who is Rh+ can have ??

Answer 45

- 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