Short case approach for Jaundice in infant, Neonates

1. Jaundice in infant
Dr Varsha Atul Shah
Senior Consultant
Singapore general hospital

3. Neonatal cholestasis
 Defined as conjugated hyperbilirubinemia occurring in the newborn as a
consequence of diminished bile flow
 Conjugated hyperbilirubinemia in a as serum
 Direct/conjugated bilirubin > 1.0 mg/dL if the total serum bilirubin (TSB) is
<5.0 mg/dL
 greater than 20% of TSB if the TSB is >5.0 mg/d

5. Clinical
presentation
 Prolonged Jaundice
 Acholic stool
 Dark urine
 Hepatomegaly
 Bronze discoloration of body
after phototherapy
 Other nonspecific signs
depending on the disease

11. Signs of Chronic liver failure

18. Nutrition
 Continue breast feeding
 Supplement MCT based feeds
 To older children: High energy diet: 200 Cal/day
 Carbohydrate : Glucose polymer
 Protein: 1-2 gm/day from vegetable source
 2-3 % calories from free fatty acids
 NG feeding in anorexic babies
 Vitamin supplement continues till 3 months after resolution of jaundice

21. Surgical Treatment
 Kasai procedure for BA
 External and internal biliary diversion for PFIC without decompensated
cirrhosis
 Choledochal cyst excision
 Cholecystectomy
 Liver transplantation

22. Kasai- Suzuki Operation
 Center where min 6 portoenterostomy/year done
 For BA not surgically correctible: excision of atretic segment, Roux-en-Y
portoenterostomy
 Prior to 8 weeks: bile flow re-established I 80-90%
 After 12 weeks; on <20%
 NO CUT_OFF for late referral
 Successful : Serum bilirubin Returns to normal
 75-100% cases had cirrhosis at laparotomy after 16 week

23. Liver Transplantation
 Bilirubin level>6mg/dl after 3 months of Kasai PE
 BA with hepatic decompensation (low albumin, prolonged INR. Ascites)
 Of the 355 transplants in child ,30% was for BA
Survival:
 5 year{ 98%
 10 years : 90%

24. Treatment
 Management of portal hypertension and its consequences
Variceal bleeding:
 Fluid resuscitation
 Blood products
 Sclerotherapy
 Balloon tamponade
 Porto venous shunting
Ascites:
 Sodium restrictions
 Diuretics{ spironolactone. Furosemides
 Albumin
 paracentesis
Thrombocytopenia is managed with platelet transfusion when clinically indicated

25. Key points
 Promptly refer newborns with prolonged NNJ with dark urine with/without
pale stool for proper investigation
 Consider EHBA as diagnosis in apparently healthy babies with pale stool
 Liver biopsy is suspected ca=ses of BA is an emergency and it should be done
and reported on urgent basis
 Surgery for BA and choledochal cyst should be done before 8 weeks