mercy health powerpoint€¦ · • inborn errors of metabolism eg galactosemia • birth trauma eg...
TRANSCRIPT
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Neonatal Jaundice
Dr Gillian Opie
Mercy Hospital for Women
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Description
not a diagnosis
Jaundice
2 22 April 2016 MCHN
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Signs
Yellow discolouration
skin
gums
sclera
Sleepiness
Poor feeding
Fever
High pitch cry
Vomiting
3 22 April 2016 MCHN
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Common Problem
60 % full term infants
80% preterm infants
Mostly unconjugated hyperbilirubinemia
4 22 April 2016 MCHN
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Jaundice - visible manifestation of hyperbilirubinemia
Hyperbilirubinemia - 1
http://reference.medscape.com/features/slideshow/strange-coloration
5 22 April 2016 MCHN
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Hyperbilirubinemia - 2
http://reference.medscape.com/features/slideshow/strange-coloration
6 22 April 2016 MCHN
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Jaundice occurs in babies ……..?
• Heme degradation
• RBC shorter lifespan
• Immature bilirubin conjugation
• Enterohepatic circulation
7 22 April 2016 MCHN
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Unconjugated bilirubin is toxic to brain
Why worry ?
Kernicterus
8 22 April 2016 MCHN
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Acute bilirubin encephalopathy
Hypotonia
Lethargy
Poor feeding
Irritability/high pitched cry
Fever/apnoea
Hypertonia with arching of neck and trunk,
Opisthotonus,
Seizures,
Coma and death 9 22 April 2016 MCHN
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10 22 April 2016 MCHN
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Babies at Significant Risk
of Jaundice
Gestation < 38 weeks
Previous sibling jaundiced
Exclusive breastfeeding
Visible jaundice
Preterm
11 22 April 2016 MCHN
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When to intervene ?
Depends on:
Preterm
Well or sick
Timing of jaundice
Reason for jaundice
12 22 April 2016 MCHN
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Any jaundice visible before 24 hours of age is
considered pathological and requires urgent
management
Begin treatment and investigation simultaneously
Refer immediately to hospital.
Timing
13 22 April 2016 MCHN
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• Serum bilirubin level (SBR)
• Baby blood group
• Direct antigen test (Coombs)
• Full blood count and film
• CRP
Investigations
14 22 April 2016 MCHN
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Due to haemolysis until proven otherwise
Rapidly rising SBR levels increase risk of neurotoxicity
Most common causes
1. ABO blood group incompatibility
Mother usually O positive
Baby usually A positive
DAT positive ( anti- A antibodies found in babies blood)
2. Rh iso-immunisation
Refugee population with previous poor maternal care
Jaundice within 24 hours
15 22 April 2016 MCHN
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• Infection
• RBC disorders eg G6PD deficiency,
Spherocytosis
• Liver disease
• Inborn errors of metabolism eg Galactosemia
• Birth trauma eg bruising,
cephalhaematoma
Other important causes
16 22 April 2016 MCHN
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Scenario
3 day old baby
37.4 weeks
Birthweight 3 kg
At home, visiting MCHN notes jaundice
Recommends SBR
Additional information
17 22 April 2016 MCHN
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60 hours since birth
Current weight 2650 gm (BW 3000 gm)
Chinese family origin
NVB
Feeding - breast only, lethargic
Urine output – 3 wet nappies last 24 hours
Stool – dark green, sticky
Jaundiced down to legs
Additional information
18 22 April 2016 MCHN
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• Screening, hand held device
• Operators must be trained to use
• Use on term infants only
• Accuracy best at lower levels of bilirubin
• Confirm result with SBR if near threshold
Not to be used
• Jaundice in infant < 24 hours age
• Significant Risk factors identified
• Previous phototherapy
Bilirubinometers
22 April 2016 MCHN 19
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20 22 April 2016 MCHN
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21 22 April 2016 MCHN
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• Gestation specific by week
• Threshold levels: birth to 8 days age; 6 hourly
intervals
• Phototherapy
• Exchange transfusion
NICE: National Institute of Clinical Excellence UK
Consensus Guidelines
Neonatal Jaundice CG 98 www.nice.org.uk/cg98
Threshold graphs / Table
22 22 April 2016 MCHN
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Phototherapy
Bruce R. Wahl/Beth Israel Deaconess Medical Center
23 22 April 2016 MCHN
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Fibreoptic phototherapy
http://www.newhealthadvisor.com/Phototherapy-for-Jaundice.html
24 22 April 2016 MCHN
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Tell Parents
• Intermittent as effective as continuous
• Breastfeeding continues
• Short breaks for feeds, cuddles, nappy changes are
• encouraged
• Explain about eye protection
• How phototherapy works
• Side effects
• Long term complications
• What might happen if phototherapy fails
Phototherapy Information
25 22 April 2016 MCHN
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Re-admit from home, 37.4W
Phototherapy
Phototherapy
26 22 April 2016 MCHN
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Not pathological
Exaggerated physiological jaundice
Poor intake
Reduced elimination – urine and bowel
Increased entero-hepatic circulation
Occurs in first 3 – 5 days of life
Not to be confused with Breastmilk Jaundice
Breastfeeding Jaundice
27 22 April 2016 MCHN
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Physiological
• Reflects liver immaturity
• Harmless
• Resolves spontaneously
• No underlying disease
• Baby not unwell
Not Physiological
Jaundice after 24 hours but
less than 10 days
28 22 April 2016 MCHN
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• One or more significant risk factors
• Unwell
• Poor weight gain
• Lethargic
• Bruising, cephalhaematoma
• Infant of diabetic mother ( polycythaemia)
• Few bowel actions, vomiting ( GIT obstruction)
• Action: refer for medical evaluation
Warning signs
29 22 April 2016 MCHN
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• Happy, healthy thriving baby
• Prolonged: may appear late and continue for
3 – 12 weeks
• Unconjugated
• Investigations do not identify cause
• Diagnosis of exclusion
• Continue Breastfeeding
Pathophysiology – “inhibitory enzymes” present
in breastmilk
Breastmilk Jaundice
30 22 April 2016 MCHN
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• Breastfeeding Jaundice / dehydration
• Breastmilk Jaundice
• Haemolysis
• Extravasated blood
• Polycythaemia
• Infection
• Increased entero-hepatic circulation (GIT
obstruction)
Causes Jaundice < 10 days
22 April 2016 MCHN 31
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Does not resolve by day 14
Must be investigated
SBR : Unconjugated vs Conjugated determines
diagnostic pathway
Prolonged jaundice
32 22 April 2016 MCHN
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Investigation important as specific treatment may be
available
Sepsis eg UTI
Hypothyroidism
Inherited liver disease
Gilbert’s syndrome
Crigler- Najjar Types 1 and 2
Prolonged Unconjugated Jaundice
33 22 April 2016 MCHN
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Suspect when
• Prolonged jaundice
• Skin colour green – brown ( not yellow)
• Urine – very dark
• Stools – acholic :pale,lemon coloured
• Unwell baby
• Not thriving
Conjugated Hyperbilirubinemia
34 22 April 2016 MCHN
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Always pathological
SBR reported 120/80 ( 80 = conjugated)
Possible causes
• Biliary Atresia until proven otherwise
• Bile duct obstruction (Choledochal cyst)
• Hepatitis
• Inborn errors of metabolism
Conjugated bilirubin
35 22 April 2016 MCHN
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Congenital paucity of bile ducts
extrahepatic
intrahepatic
Problem is stasis of bile: hepatic encephalopathy
cholangitis
Medical / Surgical emergency
Kasai procedure
Liver transplant
Biliary Atresia
36 22 April 2016 MCHN
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Early follow-up if
• early hospital discharge
• feeding not established
• exclusively breastfeeding
• risk factors identified
Pragmatic Care 1
22 April 2016 MCHN 37
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• Optimise feeding and hydration
• Advise parents of warning signs
• Visit often
Pragmatic Care 2
22 April 2016 MCHN 38
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Refer early if concerned
• direct to hospital ED if visible jaundice < 24 hrs
• unwell
• signs of conjugated hyperbilirubinemia
Refer to GP
• prolonged jaundice
• not thriving
Pragmatic Care 3
22 April 2016 MCHN 39
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Neonatal eHandbook
http://www.health.vic.gov.au/neonatalhandbook/conditions/jaundice-in-
neonates.htm
Links to NICE Threshold graphs
NICE CG 98 www.nice.org.uk/CG98
RCH clinical guidelines: Jaundice
RWH Fact Sheet : Neonatal jaundice
Resources
22 April 2016 MCHN 40