Neonatal hepatitis (common): it could be idiopathic, congenital infection (TORCH) or acquired (e.g. H1N1, HIV...).Extrahepaticbiliaryatresia: very obvious clay-color stool. The baby looks well, plays & laughs while he's yellow! Breast milk jaundiceMetabolic disorders : galactosemia, It is diagnosed by: enzyme assay, hypoglycemia & reduced substance in stool (?)Intrahepaticbiliaryatresia: Alagille syndrome is associated with dysmorphic features, congenital heart disease (pulmonary stenosis) & can be mistaken with Rubella infection.Amino acid toxicity: commonly occurs in children with total parenteral nutrition TPN. (+) history of NICU admission.Inspissated bile syndrome (uncommon): the bile duct is obstructed. Treated with rehydration & ERCP.
Maternal and Perinatal HistoryDelivery at period of gestation, Postnatal age in hoursMaternal illness during pregnancy which also includes diabetesPrevious history of malariaTraumatic delivery, delayed cord clamping, oxytocin useBirth asphyxia, delayed feeding, delay in meconium passageFamily history of jaundice, liver diseasePrevious sibling with jaundice for blood group incompatibilityKernicterus: Lethargy, poor feeding, and hypotonia. Some advanced signs are seizures, retrocollis, paralysis of upward gaze and shrill cryBreast feeding
Baby lethargic, poor feeding, temperature instability, with apnea: Sepsis Small for gestation: polycythemia,Cataract, rash: TORCH infectionsExtravascular bleed: cephalhematomaPallor: hemolysis, blood lossPetechiae: sepsis, TORCH infectionsHepatosplenomegaly: Rh-isoimmunization, sepsis, TORCH infectionsDysmorphic features, congenital heart disease (pulmonary stenosis): Intrahepaticbiliaryatresia (Alagille syndrome)
Blood group for abo and rh and other minor antigen
Torch serumtitres, Endoscopy for biliary obstruction,H/O and signs of Sepsis and screeningGalactosemia: Blood glucose and substance in stool and enzyme assaysColour of stool and urine in cholestasis
H/O for enclosed haemorrageBrest feedingHypothyroidism: thyroid levelLiver function test: in HepatitisDiabetic mother: history of diabetes in the motherRDS and asphxia: Birth historyInfection: signs of infectionDrugs: H/O drugs to motherHaemoglobin analysis and ABO grouping
Approach to neonatal jaundice
Jaundice is the visible manifestation of increased level of bilirubin in the body. It is not a disease rather a symptom of diseases. In adults sclera appears jaundiced when serum bilirubin exceeds 2 mg/dl. However it is difficult to see sclera in newborn due to difficulty in opening eye. But in new born it is very easy to see jaundice in skin.
Important problem in the 1st week of life Almost all neonates (60% Term and 80% Preterm) will have bilirubin > 5 mg/dl in the 1st week of life and become visibly jaundiced, vast majority being benign Some of the term babies (8 to 9%) have levels exceeding 15 mg/dl in 1st 7 days of life. High bilirubin level is toxic to the developing CNS
A women who delivered at homepresented on her 5th postpartum day atpediatric OPD complaining that her babylooked yellow.
Hyperbilirubinemia in the first week of life isusually of the indirect variety.1. Appearing at birth or within 24 hours of age › Hemolytic disease of newborn › Infections: intrauterine viral, bacterial; malaria › G-6PD deficiency
2. Appearing between 24-72 hours of life › Physiological › Sepsis neonatorum › Polycythemia › Concealed hemorrhages: cephalhematoma, subarachnoid bleed, IVH. › Increased enterohepatic circulation
3. Appearing after 72 hrs and within 1st week a) Sepsis neonatorum (4th - 7th days) b) Syphilis c) Toxoplasmosis
On history, the baby started turning yellowon his 2nd day. The baby was a full termmale child delivered at home. Baby iscurrently 120 hours old. There was no historyof any maternal illness during pregnancy.Delivery was uneventful. Baby immediatelycried after birth and was immediatelybreastfed.
Baby passed meconium on his first day.Urine is normal with no staining of nappies.Stool also is normal in colour.On past history, there was no H/O history ofmalaria during pregnancy.On family history, there was no H/O ofjaundice, liver disease. Previous sibling hadno history of neonatal jaundice.
Baby was well looking, feeding well, vitalswere normal, temperature was normal.There were no rashes and petechiae in thebody. Baby weighed 3 kg. Icterus waspresent. Pallor was Absent. On abdominalexamination no organomegaly waspresent. Chest was clear and CVSexamination was normal.
1. Dermal staining (By karmer) progresses from head to toe › Examined in good day light skin of forehead, chest, abdomen, thigh, legs, palms, and soles › Blanched with digital pressure and the underlying color of the skin and subcutaneous tissue should be noted.2. Transcutaneus bilirubinometer
In new born babies bilirubin metabolism isimmature which results in the occurrenceof hyperbilirubinemia in the first few days oflife. Also there is increased bilirubin load onthe hepatic cell due to physiologicalpolycythemia.
Immaturity could be at various steps ofbilirubin metabolism like: Defective uptake from plasma into liver cell Defective conjugation Decreased excretion Increased entero-hepatic circulation
First appears between hours of age Maximum intensity seen on 4-5th day in term and 7th day in preterm neonates Does not exceed 15 mg/dl Clinically undetectable after 14 days. No treatment is required but baby should be observed closely for signs of worsening jaundice.
Presence of any of the following signsdenotes that the jaundice is pathological. Clinical jaundice detected before 24 hours of age Rise in serum total bilirubin by more than 5 mg/dl/ day (>5mg/dl on first day , 10 mg/dl on second day and 12- 13 mg/dl thereafter in term babies)
Serum bilirubin more than 15 mg/dl Clinical jaundice persisting beyond 14 days of life Clay/white colored stool and/or dark urine staining the nappy yellow Direct bilirubin >2 mg/dl at any timeTreatment is required in the form ofphototherapy or exchange bloodtransfusion. One should investigate to findthe cause of pathological jaundice.
Clinical Jaundice Measure Billirubin > 12 mg/dl and < 12 mg/dl and infant < 24 hr old infant > 24 hr old Follow bilirubin Coomb’s test levelPositive Negative Identify antibody Direct Rh, ABO etc bilirubin
Direct bilirubin > 2 mg/dl < 2 mg/dl Consider HepatitisIntrauterine,viral,or Hematocrit Toxoplasmatic inf. Biliary obstr. Sepsis Galactosemia Normal or low CholestasisHemochromatosis High (Polycythemia)
Normal or Low RBC morphology Reticulocyte Count NORMAL Enclosed hemorrhage ABNORMAL Increased enterohep. circ. SpherocytosisBreast milk, Hypothyroidism, Elliptocytosis etc. Crigler-Najjar syndrome ABO Incompatibility Infant of diabetic mother Red cell enzyme def RDS, Asphyxia Alpha thallasemia Infections, Drugs(eg Drugs(eg penicillin novobiocin), galactosemia
Investigations were done. Serum totalbilirubin was found to be 10 mg/dl. Thebaby was diagnosed as a case ofphysiological Jaundice. Parents werecounseled. The baby was discharge andkept on follow up for serial analysis ofBilirubin level.
1. Bhutani V.K., Johnson Lois H., Keren Ron Diagnosis and management of hyperbilirubinemia in term neonates for a safer first week, Pediatric clinic of North America, Common issues and concerns in Newborn Nursery, Part II Aug 2004, vol 5, No. 42. Gowen CW Jr. Anemia and hyperbilirubinemia. In: Kliegman R. Nelson Essentials of Pediatrics. 5th ed. Philadelphia, Pa.: Elsevier Saunders; 2006:318.3. Paul Vinod K, Deorari Ashok K, Agrawal Ramesh et all, Newborn infants, Ghai Essential Pediatrics, 2009, 147-514. Internet