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Flashcards in peds jaundice Deck (45):
1

bilirubin labs

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

2

what can cause neonatal jaundice

lack of intestinal flora
meconium in ileus

3

pathway

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)

4

babies lack UGT and have

slow digestion

5

if bilirubin deposited in basal ganglia

kernicterus

6

babies also have ?? that hydrolyzes back into unconjugated form

Beta-glucuronidase (intestinal enzyme)
Neonates have excessive Beta-glucuronidase and low intestinal flora

7

why do you want total and direct??

determine if before hepatic or hepatic problem

8

at 24 hrs if Hgb is ?? it is worrisome

5 or greater

9

tx that can reduce hyperbilirubemia

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

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

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

11

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

Infants also have immature ??

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

hepatic glucuronyl transferase (UDP-GT).

12

Breast milk jaundice is different

present week or 2 later, something in mom's milk
helps to stop for a day or so "reset"

13

Elevated indirect (unconjugated)

Dehydration
Breastfeeding
Hemolytic processes
Difficulty conjugating

14

Elevated direct (conjugated)

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

15

Cephalohematoma

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

16

Rh and ABO incompatibility

-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.

17

O- NO (mom's blood)

-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

18

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

O-NO

19

Testing for “foreign”antibodies with Direct Coombs Test

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.

20

G6PD deficiency

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

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?

Review baby chart and order labs as appropriate:
-total and direct bilirubin
-CBC
-COOMBs
-blood type of baby and mom
-evaluate for sepsis

22

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

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.

23

hyperbilirubinemia risk factors

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

24

bilitool

use to assess if need phototx

25

When do we have to investigate the cause of jaundice?

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.

26

jaundice eval Begins with taking a ??

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?

27

jaundice gradient: Hgb concentrations

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

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

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

29

basic labs

Bilirubin Total
Bilirubin Direct

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

30

additional labs (if abnormal increase)

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

31

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

hemorrhagic/hemolytic, due to ABO incompatability

32

tx would be

phototx, hydrations, check bilirubin every 8-12 hours

33

Pathologic Jaundice

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

34

conjugated hyperbilirubinemia

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.

35

conjugated hyperbilirubinemia: Decreased Bilirubin Excretion

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

36

what hx to ask mom??

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

37

biliary atresia typical presentation

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

38

Choledocal cyst typical presentation

-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

39

elevated conjugated/direct: other causes

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

40

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

direct hyperbilirubinemia

what to do??

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??

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

42

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

Dubin-Johnson (direct)

43

do we use phototherapy for conjugated??
tx??

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

44

neurodevelopment with indirect bilirubinemia (NOT with direct)

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

45

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

-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