Neonatal Jaundice

16 June, 2011 by: colinparker

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It takes a long time and a lot of exposure to become comfortable with jaundiced newborns. Maybe we just become less cautious or less thorough over time… Most of us feel the need to slow down and consider all the possibilities, before jumping to a benign diagnosis.

Hopefully this little review will help you remember some of the basics of neonatal jaundice.
[drawing by Charlotte Parker, medium: etchysketch, yellow colouring shopped in by her dad]


Outline:Jaundice PEMcast

[CP] – intro, disclaimer.
Epidemiology:
Up to 60% of term and 80% or prem neonates become clinically jaundiced during the first week of life. Most resolve within 2 weeks and remain well throughout and require no treatment or intervention.

[KB] – Physiology:

[RR] – Kernicterus:

Literally means ‘yellow kern’ indicating the brain staining seen at autopsy. Was reducing but some reports suggest increasing incidence. Likely to be due to earlier discharges from hospital.

Bilirubin-induced neurologic dysfunction (BIND) is the term applied to the spectrum of neurologic abnormalities associated with hyperbilirubinemia.

[KB] – causes – by pathology:

Haemolysis – unconjugated:
Normal in neonates after Day 2

  • Breakdown of Hb
  • Immature liver
  • Slow gut transit
  • Bruising from delivery eg cephalohaematoma

Abnormal haemolysis:

  • Blood group incompatibility
  • G6PD deficiency
  • Hereditary Spherocytosis
  • SCD/Thallasaemia

Miscellaneous unconjugated causes:

  • Sepsis
  • Dehydration
  • Hypothyroidism
  • Trisomy 21

Conjugated Causes – always pathological:

  • Biliary Atresia
  • Hepatitis
  • Genetic disorders
    • α1 AT deficiency
    • CF
    • Galactosaemia
    • Wilsons disease
    • Allagilles syndrome

[RR] – causes – by time line:

Day 1- Pathological
• Blood Group incompatibility

Day 2 – Day 14
• Normal physiological jaundice
• Sepsis
• All other causes listed above

> 14 days

  • Unconjugated
    • Hypothyroidism
    • Abnormal haemolysis
    • Sepsis
    • Breast milk jaundice – diagnosis of exclusion
  • Conjugated
    • as above

[CP] – causes – old school classification:
Pre-hepatic
Hepatic
Post hepatic

[KB] – important features of history:
Maternal hx
Risk factors
Timing
Feeding
Weight gain
Alertness
Stool and urine colour

[CP] – examination:
General appearance
Kramer’s rule
Bruising
Plethora
Temp instability
Hepatosplenomegly
Stool colour

[RR] – investigations:
Depend on timing and wellness of neonate, may include:
Split bilirubin (conjugated & unconjugated)
LFTs
U&E
FBC
TFT
G6PD
Urine reducing substances
Blood group and DCT
Urine MC+S +/- full septic screen
Maternal TORCH screening

[KB] – treatment
Depends on underlying cause
Well baby, mild jaundice – reassurance and monitoring
Unwell neonate – sepsis protocol
Significantly elevated unconjugated bilirubin – phototherapy / exchange transfusion / IV-Ig
Conjugated – further investigation of cause, and definitive treatment as required

[All] Goodbye, thanks for listening

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