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Neonatal jaundice (Pathophysiology (Types (Prolonged (>14d term, >…
Neonatal jaundice
Pathophysiology
Kernicterus
High serum uncongugated bilirubin is neurotoxic
(deafness, cerebral palsy, seizures)
Physiological
Appears 24h, peak d3-4, resolved by 14d
Reduced foetal RBC lifespan, so increased bilirubin
Immaturity of hepatic bilirubin conjugation, so slow clearance
Absent gut flora, so bile pigment is poorly eliminated
Results in build-up of unconjugated bilirubin
Poor feeding can also contribute (e.g. dehydration with exclusive breastfeeding)
Types
Prolonged (>14d term, >21d preterm)
Pre-hepatic/hepatic causes
Prehepatic:
breastfeeding, enclosed bleeding (cephalohaematoma), haemolysis, infection (sepsis, TORCH), hypothyroidism, CF
Hepatic:
prematurity, hepatic disease
Conjugated (rare)
Hepatic or post-hepatic causes
Hepatic:
sepsis, viral hepatitis, TORCH, a1-antitrypsin deficiency, CF
Post-hepatic:
biliary obstruction (atresia, cyst)
Early (<24h birth)
ALWAYS abnormal
Pre-hepatic disease
Haemolytic disease (Rh disease, ABO incompatibility, RBC abnormalities e.g. G6PD deficiency), infection (sepsis, TORCH), severe bruising (birth trauma)
Aetiology
Pre-hepatic
Endocrine
Hypothyroidism
Haematological
Haemolytic disorders (Rh disease)
Haemaglobinopathies (GPPD, sherocytosis, elliptocytosis)
Trauma
Bruising following delivery (foceps, ventouse)
Infection
Sepsis
TORCH
Hepatic
Idiopathic
Physiological
Developmental
Prematurity
Infection
Viral hepatitis
Sepsis
TORCH
Congenital/genetic
a1-antitrypsin deficiency
Hepatic enzyme deficiency
Post-hepatic
Developmental
Biliary atresia
Biliary cyst
Infection
Sepsis
TORCH
Diagnosis
Examination
Neonatal examination
Colour, bruising, bleeding,
signs of infection
Investigations
Bloods
FBC (infection), U+Es, LFTs (bilirubin, liver disease),
clotting, TFTs (hypothyroidism)
Blood group (Rh disease), Direct Coomb's test,
Blood cultures (sepsis), virology screen (TORCH)
Bedside
Observations
Age/gestation charts for bilirubin
History
POH
Gravity/parity, delivery, gestation,
any complications (jaundice?)
PGH
Known conditions, menses,
contraception, STIs, smears
Current pregnancy
Gestation (preterm?), delivery (assisted?),
any complications (infection?)
PMH
Liver disease, clotting disorders,
haematological disorders
PC/HPC
Jaundice site, onset, radiation,
associated symptoms, timing ,
pale stools/ddark urine
DH
Drugs during pregnancy, allergies
FH
Liver disease, clotting disorders,
haematological disorders
SH
Occupation, smoking, alcohol
Epidemiology
Common
60% term, 80% preterm
Clinical
presentation
Jaundice
(often cephalo-caudal
progression)
Seizures
(kernicterus)
Management
Medical
Blue light phototherapy
Indication: severe jaundice per age/gestation charts, kernicterus
MOA: cover baby's eyes, blue light converts unconj bilirubin to water soluble form that can be excreted in the urine
SEs: hypo/hyperthermia, eye damage, diarrhoea, dehydration, rash, separation from mother
Exchange transfusion + IgG
Indication: very high serum bilirubin, kernicterus
MOA: removes bilirubin from the blood, IgG binds bilirubin
preventing BBB crossing and kernicterus
Conservative
Identify and manage cause
Definition
Jaundice occurring in the
newborn or <28d of birth
Screening
Midwife visits
Transcutaneous bilirubin measurements
Complications
Kernicterus
Acute bilirubin encephalopathy
Lethargy, poor feeding, shrill cry, hypotonia,
opisthotonus (backward head arching)
Can result in athetosis, deafness, CP, reduced IQ