In clinical practice, differentiating between physiologic jaundice from breast milk jaundice is important so that the duration of hyperbilirubinemia can be predicted. Identifying the infants who become dehydrated secondary to inadequate breastfeeding is also important. These babies need to be identified early and given breastfeeding support and formula supplementation as necessary. Depending on serum bilirubin concentration, Medical CareTreatment recommendations in this section apply only to healthy term infants with no signs of pathologic jaundice and are based on the severity of hyperbilirubinemia. In preterm, anemic, or ill infants and those with early (< 24 h) or severe jaundice (>25 mg/dL or 430 µmol/L), different treatment protocols should be pursued (see Jaundice, Neonatal).For healthy term infants with breast milk or breastfeeding jaundice and with bilirubin levels of 12 mg/dL (170 µmol/L) to 17 mg/dL, the following options are acceptable:Increase breastfeeding to 8-12 times per day and recheck the serum bilirubin level in 12-24 hours. The mother should be reassured about the relatively benign nature of breast milk jaundice (BMJ). This recommendation assumes that effective breastfeeding is occurring, including milk production, effective latching, and effective sucking with resultant letdown of milk. Breastfeeding can also be supported with manual or electric pumps and the pumped milk given as a supplement to the baby.Continue breastfeeding and supplement with formula.Temporary interruption of breastfeeding is rarely needed and is not recommended unless serum bilirubin levels reach 20 mg/dL (340 µmol/L). For infants with serum bilirubin levels from 17-25 mg/dL (294-430 µmol/L), add phototherapy to any of the previously stated treatment options. The reader is referred to the American Academy of Pediatrics' practice parameter on the management of hyperbilirubinemia in healthy full-term newborn infants.The most rapid way to reduce the bilirubin level is to interrupt breastfeeding for 24 hours, feed with formula, and use phototherapy; however, in most infants, interrupting breastfeeding is not necessary or advisable.Phototherapy can be administered with standard phototherapy units and fiberoptic blankets. See the image below.
GP notebook :Inactivated or killed vaccines are generally safe and the only absolute contraindication is a severe local or general reaction to a previous dose.Live vaccines are contraindicated in pregnancy and in those who are on systemic steroid therapy or immunosuppressed for any reason. Vaccination may however be performed if the risks of infection exceed the risks of vaccination.Live vaccines should either be given simultaneously (if possible at different sites) or after a 3 week gap. (Except when BCG is given to infants when oral polio need not be delayed).12 weeks should elapse after a dose of human immunoglobulin before a live vaccine is administeredavoid during acute febrile illnessesBCG should not be given to eczema patients though otherwise eczema, hayfever, asthma and topical steroids are not contraindications to immunization.Premature infants, and those suffering from heart and lung diseases should be immunised according to the usual schedules. Premature infants should be immunized at the times recommended for full term babies, without correction for gestational ageThe following are not contraindications to vaccination, but folklore has had it in the past that they were:previous history of infectionstable neurological conditionantibiotic therapyallergic history, such as allergy to egg proteinsbreast feedingsibling of immune suppressed patient, except for live polio vaccine where a killed vaccine should be usedweightneonatal jaundice
Neonatal Jaundice 1
DR.FADI ALFAQAWIMEDICAL OFFICERUNRWA10th FEB 2013NEONATAL JAUNDICE1-PHYSIOLOGICALEmail: firstname.lastname@example.org
Objectives:1-How to-Suspect?-Measure?-Diagnose?2-How to approach? And When torefer to hospital ?3-How to manage ?3-What to tell parents ?4-To Vaccinate or not ?
Introduction: ~60% of term and 80% of preterm babiesdevelop jaundice in the first wk of life. 10% of BF babies are still jaundiced at1 month. For most babies, jaundice is not an indicationof an underlying disease (termed physiologicaljaundice) is generally harmless. Prolonged jaundice –persisting beyond thefirst 14 days in term babies and beyond 21days in PT babies.
How to suspect:Babies are more likely to develop significanthyperbilirubinaemia if they have: gestational age under 38 weeks. a previous sibling with NJ requiringphototherapy. mothers intention to breastfeed exclusively Visible jaundice in the first 24 hours.
How to measure: Kramer’sIndex When looking forjaundice (visualinspection):1-check the nakedbaby in bright &preferably natural light2-examine the sclerae,gums and blanchedskin is useful across allskin tones.1- Face 5 mg /dl2-Upper trunk 103-Lower trunk & thighs 124-Arms &lower legs 155-Palms and soles>15
How to measure: TCBilirubinometer Use a TC bilirubinometer inbabies with GA of 35 weeks ormore and PN age of >24 hours If a TC bilirubinometer is notavailable, measure the serumTB. If a TC bilirubinometermeasurement > 250μmol/l (15mg/dl) … check the result bymeasuring the serum TB
How to diagnose: Causes 1. Appearing within 24 hours of age-Hemolytic disease of newborn: Rh, ABO and minor groupincompatibility-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 hours-Sepsis neonatorum-Neonatal hepatitis-Extra hepatic biliary atresia
Physiological Jaundice: Immaturity in bilirubin metabolism at multiplesteps... Characteristics:· First appears between 24-72 hours of age· Maximum intensity seen on 4-5th day in term and7th day in preterm neonates· Does not exceed 15 mg/ dl· Clinically undetectable after 14 days.· No treatment is required but baby should beobserved closely for signs of worsening jaundice.
Pathological Jaundice:1-Clinical jaundice detected before 24 hours of age.2-Rise in serum bilirubin by > 5 mg/dl/day.3-Serum bilirubin >15 mg/dl.4-Clinical jaundice persisting beyond 14 days of life.5-Clay/white colored stool and/or dark urine stainingthe clothes yellow.6-Direct bilirubin >2 mg/ dl at any time.*One should investigate to find the cause.*Treatment is required in the form of phototherapy orEPT.
How To Approach: Check birth wt, GA ,PN age. FH/o Jaundice or anemia or neonatal death.. Maternal and perinatal history… Ask when jaundice was first noticed ? Assess clinical condition… Physiological or Pathological… Look for clinical picture of kernicterus inNewborns..
Refer for further investigation if: Clinically unwell… poor feeding and lethargy … Jaundice within 24 hours of life. Jaundice below umbilicus, corresponding to serum bilirubin of12-15 mg/dl (200-250 μmol/l ). Jaundice up to level of the sole of the feet - likely to needexchange transfusion. Rapid rise of serum bilirubin of more than 8.5 μmol/l /hour(>0.5 mg/dl/hour). Prolonged jaundice of >14 days - other causes/conditionsneed to be excluded e.g. neonatal hepatitis, biliary atresia. Family history of significant haemolytic disease or kernicterus Clinical symptoms/signs suggestive of other diseases e.g.sepsis. Direct bilirubin >20 %
Reduce level of bilirubin and prevent its toxicity by:1-Early feeds and adequate hydration.2-Reduction of Bilirubin by (Threshold table):1-Phototherapy 2-IVIG 3-EBT.How to manage ingeneral :
What to tell parents: Offer parents or carers information about NJ that is tailored to their needsand expressed concerns. Care should be taken to avoid causingunnecessary anxiety to parents or carers. Information should include:1-Factors that influence the development of significant hyperbilirubinaemia2-How to check the baby for jaundice3-What to do if they suspect jaundice4-The importance of recognising jaundice in the first 24 hours and of seekingurgent medical advice5-The importance of checking the babys nappies for dark urine or pale chalkystools6-The fact that NJ is common, &reassurance that it is usually transient andharmless7-Reassurance that breastfeeding can usually continue.8-Provide lactation/feeding support to breastfeeding mothers whose baby isvisibly jaundiced.
To vaccinate or not: Physiological Jaundice IS NOT acontraindication.