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Maryam AL-Qahtani

• Draw up a diagnostic and treatment plan on the basis of the probability diagnosis?

• Would it make any difference to your differential diagnosis if the child was 1 day old rather than 3 day old ? OR 10 day old? Give reasons for your answer.

Learning Objectives

n ro uction

Jaundice occurs in approximately 60% of newborns but only a few will require investigation and treatment.

Draw up a

diagnostic on the

basis of the

probability

diagnosis?

A transcutaneous bilirubinometer:

Serum bilirubin:

LFTs:

Aspartate aminotransferase (ASAT ) and alanine aminotransferase (ALAT ) levels are elevated in:

Hepatocellular disease.

Alkaline phosphatase and γ-glutamyltransferase(GGT) levels are often elevated in:

cholestatic disease.

Toxoplasmosis, rubella, herpes

simplex

Surface swabs including umbilicus,

throat swabs, urine culture, blood

culture, lumbar puncture, CXR.

Infection screen:

Reducing substance in urine:

Screening test for galactosaemia

Thyroid function tests:

Blood type and Rh determination in mother and

infant.

Reticulocyte count.

Haemoglobin and haematocrit values.

Direct coombs test

Peripheral blood film for erythrocyte morphology.

Red cell enzyme assays: glucose-6-phosphate

dehydrogenase activity (G6PD deficiency), pyruvate

kinase deficiency.

Hemolytic work-up :

Ultrasound, radionuclide scan, liver biopsy

may be required for cholestatic jaundice in

the differentiation between hepatitis and

biliary atresia.

Draw up a treatment plan on the

basis of the probability diagnosis?

Doctors, nurses, and family members will

watch for signs of jaundice at the hospital

and after the newborn goes home.

When treatment is needed,

the type will depend on:

•The baby's bilirubin level.

•How fast the level has been

rising.

•Whether the baby was born

early .

•How old the baby is.

IFPhysiological

jaundice :The type seen in most newborns -- does not require

aggressive treatment.

with frequent feedings the baby often (up to 12 times a day) to encourage frequent bowel movements. These help remove bilirubin through the stools. And exposure to indirect sunlight at home.

It will typically disappear in a few days (within 1 -2wk.)

Doctors may test the baby's bilirubin levels during that time to make sure it has not gotten worse.

Phototherapy treatment

Exchange transfusion

Intravenous immunoglobulin

IF baby has more severe jaundice, she/he may need

treatment including:

When unconjugated bilirubin is > 12 mg/dl (> 205.2 μmol/L)

And when unconjugated bilirubin is > 15 mg/dl at 25 to 48 h, 18 mg/dl at 49 to 72 h, and 20 mg/dl at > 72 h

Phototherapy is not indicated for conjugated hyperbilirubinemia.

Indication:

Phototherapy treatment

Phototherapy is the use of light to photoisomerize

unconjugated bilirubin into forms that are more water-

soluble and can be excreted rapidly by the liver and

kidney.

It provides definitive treatment of neonatal

hyperbilirubinemia and prevention of kernicterus.

Phototherapy treatment

Treatment with phototherapy is

successful for almost all infants.

Side effects:

• Phototherapy is very safe, but it can have

temporary side effects, including a skin rash and

loose bowel movements.

• Overheating and dehydration can occur if the infant

does not get enough breast milk or formula.

Phototherapy is stopped when bilirubin levels decline

to a safe level.

is done to prevent or minimize

bilirubin-related brain damage.

The transfusion replaces an infant's

blood with donated blood in an attempt

to quickly lower bilirubin levels.

performed in infants who have not

responded to other treatments

Exchange transfusion :

oBilirubin >340 micromol/L

oWho have signs of or are at significant

neurologic risk of bilirubin toxicity

Indications:

Risks of exchange transfusions:(uncommon) include:

bradycardiavasospasmair embolisminfectionthrombosis

If a baby have different blood types, may get immunoglobulin (a blood protein) through a needle

into a vein.

This can help her treat her jaundice so that she’s less likely to need an

exchange transfusion.

Intravenous immunoglobulin

(also called IVIg):

Would it make any difference to your

differential diagnosis if the child was 1 day old rather than 3 day old ?

OR 10 day old? Give reasons for your

answer.

Best classified by age of onset and

duration:

1.Early: within 24 hrs of life.

2. Intermediate: 2 days to 2

weeks.

3.Late: persists for >2 weeks.

Early:

Haemolytic causes: Rh incompatibility- ABO incompatibility-

G6PD deficiency

Congenital infection .

Increased haemolysis due to haematoma.

Maternal autoimmune haemolytic anaemia: eg, systemic lupus

erythematosus.

Crigler-Najjar syndrome.

Gilbert's syndrome.

• Physiological jaundice

• Breast milk jaundice (inadequate

intake)

• Sepsis

• Haemolysis

• Crigler-Najjar syndrome (glucuronyl

transferase absent/reduced)

• Polycythaemia

• Hypothyroidism, hypopituitarism.

• Galactosaemia.

Intermediate:

• Conjugated (dark urine, pale stools):

– Bile duct obstruction

– Biliary atresia

– Neonatal hepatitis

• Unconjugated:

– Physiological (rare).

– Breast milk jaundice

– Infection

– Hypothyroidism

References

• Kliegman Book.

• Merck Manual

• http://www.health.vic.gov.au/neonatalhandbook/conditions/jaundice-in-

neonates.htm

• http://www.nlm.nih.gov/medlineplus/ency/article/001559.htm

• http://www.emedicinehealth.com

• http://www.healthline.com

• http://www.patient.co.uk/doctor/neonatal-jaundice-pro

• http://www.nhs.uk/conditions/jaundice-newborn/pages/treatment.aspx

Thank you