DNB resident learning module

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DNB resident learning module

  1. 1. Resident Teaching Sessions in Neonatology Case – The Jaundiced Infant dnbpaediatrics.blogspot.in
  2. 2. dnbpaediatrics.blogspot.in case • Mother: 24 year old G2T0P0A1L0 Spontaneous labour at 38 weeks • Delivery:Delayed 2nd stage Forceps • Infant: Male Birthweight 3.8kg Pale and floppy, given free flow oxygen Apgars 61, 95 minutes
  3. 3. dnbpaediatrics.blogspot.in case – Question 1 • Asked to see at 18 hours of age because of jaundice and poor feeding • What further details of the history may be helpful?
  4. 4. dnbpaediatrics.blogspot.in case – Answer 1 • Mother : – Group B ß-hemolytic strept negative – Rubella immune – HBsAg negative, HIV negative – Maternal blood group: O rhesus negative – Caucasian, no family history of jaundice • Healthy pregnancy, prenatal vitamins, no meds • Rupture of membranes: 32 hours • Breast feeding (unsuccessfully)
  5. 5. dnbpaediatrics.blogspot.in case – Question 2 • What would you look for on examination of the infant?
  6. 6. dnbpaediatrics.blogspot.in case – Answer 2 • Looks well • No dysmorphic features, no rash • Jaundiced, pale • Heart sounds normal, no murmur, cap refill 2 sec • No hepatosplenomegaly • Forceps marks and bruising to face, “boggy” feeling to scalp • HR 140/min, RR 40/min, BP 48/34(43), T 36.8
  7. 7. dnbpaediatrics.blogspot.in case – Question 3 • What would be your first line of investigations?
  8. 8. dnbpaediatrics.blogspot.in case – Answer 3 • CBC, diff, film • Bilirubin (unconjugated, conjugated) • Glucose, lytes • Blood culture • Blood group and Coombs test
  9. 9. dnbpaediatrics.blogspot.in case - Results • Hb 110g/L, hct 0.31, WBC 27, NPL 10.9, plat 183 • Bilirubin: unconj 210 umol/L, conj 3 umol/L • Glucose 3.2 mmol/L • Na 138 mmol/L, K 4.5 mmol/L • Infant blood group A rhesus positive • Direct Coombs test strongly positive
  10. 10. dnbpaediatrics.blogspot.in Coombs test • Direct: detects antibodies on the patient’s cells. • Indirect: detects antibodies in the patient’s serum
  11. 11. dnbpaediatrics.blogspot.in case – Question 4 • What management would you institute immediately?
  12. 12. dnbpaediatrics.blogspot.in case – Answer 4 • Phototherapy • Optimise fluid intake (oral/nasogastric/IV) • Antibiotics • Repeat bilirubin in 4 hours
  13. 13. dnbpaediatrics.blogspot.in Phototherapy • Isomerisation of water insoluble unconjugated bilirubin to a more water soluble form (lumirubin). • Most effective is blue light: wavelength 400- 500nm. White light often used. • Side effects: – Increased fluid losses (1ml/kg/hr extra required) – Irritability – Loose stools – Temperature instability – Maculo-papular rash – Separation of infant from mother
  14. 14. dnbpaediatrics.blogspot.in case – Question 5 • After 4 hours of phototherapy and IV fluids, the bilirubin is now 260 umol/L • What further management options would you consider?
  15. 15. dnbpaediatrics.blogspot.in case – Answer 5 • Exchange transfusion: – “Double volume” 160 cc/kg, removes 80% of red cells, 50% bilirubin • Intravenous immunoglobulin
  16. 16. dnbpaediatrics.blogspot.in case – Question 6 • After 6 days of phototherapy, the bilirubin is measured at 140umol/L (unconjugated) after 12 hours off phototherapy • What complications would you look for, and what would be your follow-up plan?
  17. 17. dnbpaediatrics.blogspot.in case – Answer 6 • Complications – Rebound hyperbilirubinemia – Anemia – Manifested as lethargy, poor feeding, poor growth • Hct prior to discharge, continue to monitor bilirubin
  18. 18. dnbpaediatrics.blogspot.in Causes of hyperbilirubinemia • Unconjugated – Hemolysis • DAT positive (ABO incompatibility, rhesus incompatibility, SLE, drugs) • DAT negative (RBC enzyme deficiencies e.g. G6PD, pyruvate kinase) – No hemolysis (Physiologic, breast milk, Gilbert, Crigler-Nijjar, hypothyroidism) • Conjugated (obstructive, infection, drugs, metabolic); usually late
  19. 19. dnbpaediatrics.blogspot.in Benign unconjugated hyperbilirubinemia • Physiological jaundice – Increased red blood cell mass, shortened RBC life span and hepatic immaturity of ligandin and glucuronyl transferase • Breast milk jaundice – Beta-glucoronidase in milk leads to deconjugated of bilirubin in the bowel and increased enterohepatic circulation – Reassure and do not stop breast feeding
  20. 20. dnbpaediatrics.blogspot.in Prolonged hyperbilirubinemia • Unconjugated – Hypothyroidism, urine tract infection, hemolysis • Conjugated – Biliary atresia, TORCH infection, metabolic disorder, alpha-1-antitrypsin deficiency, cystic fibrosis, TPN cholestasis, idiopathic neonatal hepatitis
  21. 21. dnbpaediatrics.blogspot.in Learning Objectives • Describe the management of the infant with unconjugated hyperbilirubinemia • List the common causes of unconjugated and conjugated hyperbilirubinemia in the newborn period

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