NEONATAL JAUNDICE (HYPERBILIRUBINEMIA)

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<B>NEONATAL JAUNDICE (HYPERBILIRUBINEMIA)</B></div> <div> <A HREF="id29.htm" TARGET="_top" TITLE="Hyaline Membrane Disease (Respiratory Di"><U><B>Hyaline Membrane Disease (Respiratory Distress Syndrome) (HMD) (RDS</B></U></A></div> <div> <A HREF="id30.htm" TARGET="_top" TITLE="infectious disease"><U><B>infectious disease</B></U></A></div> <div> <A HREF="id32.htm" TARGET="_top" TITLE="HEMORRHAGIC DISEASE IN A NEW BORN"><U><B>HEMORRHAGIC DISEASE IN A NEW BORN</B></U></A></div> <div> <A HREF="id33.htm" TARGET="_top" TITLE="OPTIC NERVE GLIOMA"><U><B>OPTIC NERVE GLIOMA</B></U></A></div> <div> <A HREF="id36.htm" TARGET="_top" TITLE="New Born Assessment "><U><B>New Born Assessment </B></U></A></div> <div> <A HREF="id38.htm" TARGET="_top" TITLE="laryngomalacia"><U><B>laryngomalacia</B></U></A></div> <div> <A HREF="id39.htm" TARGET="_top" TITLE="CRANIOSYNOSTOSIS "><U><B>CRANIOSYNOSTOSIS </B></U></A></div> <div> <A HREF="id40.htm" TARGET="_top" TITLE="DANDYWALKER MALFORMATION "><U><B>DANDY-WALKER MALFORMATION </B></U></A></div> <div> <A HREF="id41.htm" TARGET="_top" TITLE="DEJERINESOTTAS DISEASE "><U><B>DEJERINE-SOTTAS DISEASE </B></U></A></div> <div> <A HREF="id42.htm" TARGET="_top" TITLE="DOWN SYNDROME "><U><B>DOWN SYNDROME </B></U></A></div> <div> <A HREF="id43.htm" TARGET="_top" TITLE="Respiratory Syncytial Virus (RSV)"><U><B>Respiratory Syncytial Virus (RSV)</B></U></A></div> <div> <A HREF="id44.htm" TARGET="_top" TITLE="FABRY DISEASE "><U><B>FABRY DISEASE </B></U></A></div> <div> <A HREF="id45.htm" TARGET="_top" TITLE="PRADERWILLI SYNDROME "><U><B>PRADER-WILLI SYNDROME </B></U></A></div> <div> <A HREF="id37.htm" TARGET="_top" TITLE="new born fun"><U><B>new born fun</B></U></A></div> <div> <A HREF="id46.htm" TARGET="_top" TITLE="RETT SYNDROME "><U><B>RETT SYNDROME </B></U></A></div> <div> <A HREF="id47.htm" TARGET="_top" TITLE="Alexander Disease"><U><B>Alexander Disease</B></U></A></div> <div> <A HREF="id49.htm" TARGET="_top" TITLE="leukemia"><U><B>leukemia</B></U></A></div> <div> <A HREF="id17.htm" TARGET="_top" TITLE="Contact Me"><U><B>Contact Me</B></U></A></div> </td> <td valign="top" height=370 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> NEONATAL JAUNDICE (HYPERBILIRUBINEMIA)</div> <div> <IMG BORDER="0" SRC="Symb075c00b7011800000000.gif" HEIGHT="19" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">As we all know <FONT SIZE="4" COLOR="#800000" FACE="Arial" >jaundice</FONT> is seen when the skin and the sclera (white of the eye) becomes yellow.</div> <div> <IMG BORDER="0" SRC="Symb075c00b7011800008000.gif" HEIGHT="19" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Jaundice<FONT SIZE="4" COLOR="#000000" FACE="Arial" > is fairly common in </FONT>newborn<FONT SIZE="4" COLOR="#000000" FACE="Arial" >s and is seen in 90% of the babies. </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b7011800000000.gif" HEIGHT="19" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This is 'normal  <A NAME="physio"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>physiological <FONT SIZE="4" COLOR="#800000" FACE="Arial" >jaundice</FONT>' seen usually on second or third day of life and disappears by the 7th – 10th day.</div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In a <FONT SIZE="3" COLOR="#800000" FACE="Arial" >newborn</FONT>, the red cells in the blood are broken earlier and faster as compared to the adults. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">As a result ' <A NAME="bili"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>bilirubin' (pigment causing <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT>)[see gi in pathology lectures] which is produced from these broken red cells accumulates in the body causing <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT>. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">When the body is in the womb, this bilirubin is washed away by the placenta into the mother's circulation and removed. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The liver (which removes the bilirubin from the blood) in the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >newborn</FONT> is a little immature and takes some days to start functioning properly. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hence <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT> in the baby occurs commonly.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Even though there is a well established association between breast feeding and an increased risk of neonatal hyperbilirubinemia in the first week of life, this should in no way inhibit, prevent or discourage mothers from breastfeeding. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In babies who nurse poorly, the likelihood of becoming <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT>d is even greater. It must also be remembered that babies of 36 to 37 weeks’ gestation (or less) do not nurse as well as more mature babies. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">One study has shown that infants at 37 weeks were four times more likely to have a serum bilirubin > 230 mmol/L than those of 40 weeks’ gestation.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Other risk factors for developing <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT> include: [see below]</div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">ABO incompatibility,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> maternal diabetes, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">use of oxytocin in labor,</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Asian male babies, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">presence of bruising and cephalhematoma, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">and a family history of neonatal </B><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B>jaundice</B></FONT><B>.</B></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Though 90% of the times, <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT> in a <FONT SIZE="3" COLOR="#800000" FACE="Arial" >newborn</FONT> is the physiological <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT>, some features may be suggestive of another disease. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If the following signs appear,can be bad</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000008000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Jaundice<FONT SIZE="3" COLOR="#000000" FACE="Arial" > appearing within first 24 hours of life. </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000008000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Jaundice<FONT SIZE="3" COLOR="#000000" FACE="Arial" > persists even after 14 days of life </FONT></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Baby is not feeding well. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Baby's urine becomes yellow in color </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">The stools of the baby are pale or clay colored (almost whitish) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Baby appears lethargic, irritable. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Prolonged <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT> may be seen in premature babies (due to immature liver), some red cell defect, infection, thyroid disorder, liver disorder etc. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hence if the baby is still <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT>d after two weeks after birth, some blood and urine tests are required to determine the cause and early treatment.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Some babies may have prolonged <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT> inspite of being completely well. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This is usually seen in breast fed babies. Breast-feeding is continued and the <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT> will disappear over time.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Usually <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT> in <FONT SIZE="3" COLOR="#800000" FACE="Arial" >newborn</FONT> is not at all dangerous. </div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Since, <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT> in babies is not usually harmful and disappears by the 10 th day, no treatment is required.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> However some babies may require treatment in the form of light ( <A NAME="photo"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>phototherapy). </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">This is done after the doctor checks the baby's blood for high bilirubin levels. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">It is given with the help of a special light. Baby is placed under this light completely naked except for presence of eye pads (to shield the eyes) and cloth to cover the genitals.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> Phototherapy helps to remove bilirubin faster from the baby. The baby should be fed properly and adequately during phototherapy to ensure a good urine output. Phototherapy is usually given for few days.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Babies with hypothyroidism may have prolonged <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT> beyond 2 weeks and they should be screened for thyroid disorder and if detected, appropriate treatment should be given. Babies with red cell defects may require further treatment. If liver disease is the cause of <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT> (though very rare), early treatment should be initiated to prevent further damage to the liver.</div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Thus, </U><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><U>jaundice</U></FONT><U> in a </U><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><U>newborn</U></FONT><U> is usually seen in 90% of babies, is not harmful and disappears by 10th day of life. Feed your baby adequately and properly and watch for the warning signs. </U></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In the neonate, dehydration results primarily from an inadequate amount of fluid intake. Breast feeding, first-time mothers and an infant who does not latch properly are risk factors for developing dehydration. Other factors include the presence of inverted nipples, previous reduction surgery, cesarean section, use of analgesics and an immature infant with a weak sucking ability. </div> <bR> <bR> <div> <B>What screening investigations should be done in a </B><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B>jaundice</B></FONT><B>d infant?</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Initially a total bilirubin will suffice. If there is a suspicion of hemolytic disease or anemia (e.g. clinical <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT> at < 24 hours or a MBR > 230 mmol/L in the first 48 hours), then a blood type and Coombs test should be done. In addition a CBC, smear and reticulocyte count should be ordered. If the neonate is a male Asian or Mediterranean infant with late onset <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT> and a MBR> 260 mmol/L, a G6PD screen should be done.</div> <div> <I> <TABLE BORDER="2" CELLPADDING="2" CELLSPACING="1" WIDTH="689" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 508 WIDTH="677"><div> Types of newborn jaundice :</div> <bR> <div> Physiological jaundice:</div> <div> Some degree of jaundice is evident in a lot of newborns usually on the 2nd day of life. It peaks around the 4th to 5th day & the yellowness disappears by the end of the 1st week.Technically speaking the bilirubin levels are between 10-16 mg%.</div> <bR> <div> Pathological jaundice:</div> <div> If the bilirubin builds up too high in the body that is more than 17mg% within the first week then it may be toxic to the brain and it can cause permanent brain damage. This can occur due to some infection to the baby, mismatch between the baby’s and mother’s blood group or due to some structural defects in the liver.</div> <bR> <div> Jaundice of prematurity:</div> <div> It occurs frequently in premature babies because the liver takes much more time to be able to handle the bilirubin levels.    </div> <bR> <bR> <div>   Breast Feeding</div> <bR> <div> Breast milk jaundice:</div> <div> A particular compound in the mother’s milk can lead to jaundice in a few babies. It usually occurs the 4th day onwards. However sometimes it can reach high levels be prolonged.</div> <div> Stopping breast feeding & feeding only formula for 2 days subsides the jaundice and then breast feeding can be resumed .</div> <div>  </div> <bR> </tD> </tR> </TABLE></I></div> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div> <I><B><U>Based on bilirubin conjugation</U></B></I></div> <div> <B><U>Unconjugated</U></B><B> </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Physiologic </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Breast milk jaundice </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Intestinal obstruction </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hemolytic disease:</div> <div> - <FONT SIZE="3" COLOR="#FF0000" FACE="Arial" ><B>Maternal fetal blood group incompatibilities</B></FONT></div> <div> <B>- Red blood cell enzyme deficiencies</B></div> <div> <B>- Congenital disorders:</B></div> <div> <B>a. Spherocytosis</B></div> <div> <B>b. Thalassemia (less likely)</B></div> <div> <B>c. `congenital non-spherocytic hemolytic anemias'</B> </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Resorption of extravascular blood</div> <div> - Cephalohematoma</div> <div> - Subdural hematoma</div> <div> - Ingestion of maternal blood at time of delivery </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Polycythemia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hypothyroidism </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hereditary causes: Criggler-Najjar syndrome </div> <div> <I>* 4-5-6- cause unconjugated hyperbilirubinemia secondary to increased production.</I></div> <div> <B><U>Conjugated</U></B></div> <div> Neonatal hepatitis </div> <div> Biliary obstruction</div> <div> - Biliary atresia</div> <div> - Biliary hypoplasia</div> <div> - Paucity of bile ducts</div> <div> - Choledochal cyst </div> <bR> <div> <B>Sepsis</B> - MORE COMMON THAN 1 OR 2 ABOVE! </div> <div> TORCH infections </div> <div> Alpha one antitrypsin deficiency </div> <div> Galactosemia </div> <div> Dubin-Johnson syndrome </div> <div> Rotor syndrome </div> <bR> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="641" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 20 ><NOBR><div> <B>MANAGEMENT OF HYPERBILIRUBINEMIA IN THE HEALTHY TERM </B><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B>NEWBORN</B></FONT><B> </B><FONT SIZE="1" COLOR="#000000" FACE="Arial" ><B>(1)</B></FONT></div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER COLSPAN=4 HEIGHT= 19 WIDTH="625"><div> Total Serum Bilirubin Level in mmol/L</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 38 ><NOBR><div> Age(hours)</div> </NOBR></tD> <tD VALIGN=CENTER WIDTH="134"><div> Consider phototherapy <FONT SIZE="1" COLOR="#000000" FACE="Arial" >(2)</FONT></div> </tD> <tD VALIGN=CENTER WIDTH="89"><div> Phototherapy <FONT SIZE="1" COLOR="#000000" FACE="Arial" >(3)</FONT> </div> </tD> <tD VALIGN=CENTER WIDTH="307"><div> Exchange transfusion if intensive phototherapy fails <FONT SIZE="1" COLOR="#000000" FACE="Arial" >(4)</FONT></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="86"><div> < 24 <FONT SIZE="1" COLOR="#000000" FACE="Arial" >(5)</FONT></div> </tD> <tD VALIGN=CENTER WIDTH="134"><div> -</div> </tD> <tD VALIGN=CENTER WIDTH="89"><div> -</div> </tD> <tD VALIGN=CENTER WIDTH="307"><div> -</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="86"><div> 25-48</div> </tD> <tD VALIGN=CENTER WIDTH="134"><div> > 170</div> </tD> <tD VALIGN=CENTER WIDTH="89"><div> > 260</div> </tD> <tD VALIGN=CENTER WIDTH="307"><div> > 340</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="86"><div> 49-72</div> </tD> <tD VALIGN=CENTER WIDTH="134"><div> > 260</div> </tD> <tD VALIGN=CENTER WIDTH="89"><div> > 310</div> </tD> <tD VALIGN=CENTER WIDTH="307"><div> > 430</div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="86"><div> > 72</div> </tD> <tD VALIGN=CENTER WIDTH="134"><div> > 290 </div> </tD> <tD VALIGN=CENTER WIDTH="89"><div> > 340 </div> </tD> <tD VALIGN=CENTER WIDTH="307"><div> > 430</div> </tD> </tR> </TABLE></div> <DIV ALIGN="LEFT"></DIV> <div> (1) Refers to infants <FONT SIZE="3" COLOR="#800000" FACE="Arial" >born</FONT> at 37 weeks or more gestation</div> <div> (2) Phototherapy at these levels is a clinical option, meaning that the intervention may be used on the basis of individual clinical judgement.</div> <div> (3) If hemolysis is likely or present phototherapy should begin at lower MBR levels (220-250).</div> <div> (4) Intensive phototherapy refers to double or triple phototherapy with lights placed above and below the infant.</div> <div> (5) Term infants who are clinically <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT>d at < 24 hours old are not considered healthy and require further evaluation (See text)</div> <bR> <div> <B>How can </B><FONT SIZE="3" COLOR="#800000" FACE="Arial" ><B>jaundice</B></FONT><B> and the dehydration be anticipated?</B> </div> <div> Infants who are clinically <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT>d < 24 hours of age, or breastfeeding infants < 37 weeks gestation with a primigravida mother should not be discharged from hospital in less than 48 hours. Any infant discharged home within 48 hours of delivery needs timely follow-up with a competent healthcare professional within 2 to 3 days of discharge. By the third day of life the healthy term infant should stop losing weight, have lost no more than 10% of birth weight, be passing milk stools (non-meconium) at least 2 to 3 times per day, wet at least 5 to 6 diapers per day and latch well on to the breast. The mother should experience some engorgement and expect to feed the infant a minimum of 6 to 8 times per day. For mothers experiencing difficulty with breast feeding, early contact by telephone or in person with a lactation aid consultant should be very strongly encouraged. </div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="11" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="7"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="7" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <bR> <DIV ALIGN="LEFT"></DIV> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="632" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" BGCOLOR=#FFFF00 > <tR> <tD VALIGN=CENTER HEIGHT= 20 WIDTH="622"><div> <B>PEARLS</B></div> </tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 76 ><NOBR><div> <B>High risk factors in the </B><B>jaundice</B><B>d neonate </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Clinical </B><B>jaundice</B><B> first 24 hours </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Jaundice</B><B> in the < 37 week gestation infant </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Male, oriental, family history of neonatal </B><B>jaundice</B><B> </B></div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 20 ><NOBR><div> <B>Timely follow-up for infants discharged at < 48 hours after birth </B></div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER HEIGHT= 76 WIDTH="622"><div> <B>Monitor feeding closely: High risk factors </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Weight loss > 10% of birth weight </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Expect > 6 wet diapers in 24 hours </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Expect > 2 to 3 stools/24 hours </B></div> </tD> </tR> </TABLE></div> <bR> <div> If <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT> is left untreated, high levels of bilirubin can develop in the blood and possibly be absorbed into the brain cells, leading to irreversible brain damage. Extreme <FONT SIZE="3" COLOR="#800000" FACE="Arial" >jaundice</FONT> that leads to brain damage, called kernicterus or bilirubin encephalopathy, occurs very rarely and only when the bilirubin level in the blood exceeds a level of 25-30 mg/dl. This condition can also lead to mental impairment, motor problems, and hearing loss,</div> <bR> <bR> <div> <TABLE BORDER="2" CELLPADDING="2" CELLSPACING="1" WIDTH="998" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 3827 ><NOBR><div> JAUNDICE - NEONATAL </div> <div> DEFINITION:</div> <div> A disorder caused by an excess of unconjugated or conjugated bilirubin in the newborn period. </div> <div> EPIDEMIOLOGY:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">incidence: ? </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">age of onset: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">newborn period </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">risk factors: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">see differential diagnosis </div> <div> DIFFERENTIAL DIAGNOSIS FOR UNCONJUGATED HYPERBILIRUBINEMIA:</div> <div> 1. Increased Production</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1. Hemolytic Diseases </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Intrinsic </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Membrane </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Enzyme </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hemoglobin Synthesis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Extrinsic </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Immune </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Non-immune </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">2. Infection </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sepsis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">TORCH infections </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">3. Extravesated </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">bruising </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">cephalohematoma </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">delayed cord clamping </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">transfusion (twin-twin, maternal-fetal) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">4. Enterohepatic Circulation Increase </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">delayed feeding </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">delayed stooling </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">dehydration </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">GI obstruction </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">5. Polycythemia </div> <div> 2. Decreased Conjugation</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1. Crigler-Najjar Syndrome - I </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">2. Gilbert Syndrome </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">3. Lucy-Driscoll Syndrome </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">4. Breast Milk Jaundice </div> <bR> <bR> <bR> <div> <B><U>DIFFERENTIAL DIAGNOSIS OF CONJUGATED HYPERBILIRUBINEMIA:</U></B></div> <div> 1. Intrahepatic Cholestasis</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1. Persistent </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Alagille Syndrome (arteriohepatic dysplasia) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Benign Recurrent Intrahepatic Cholestasis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Byler Disease </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cholestasis - Lymphedema </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Neonatal Hepatitis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">NSP of Interlobular Bile Ducts </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">2. Acquired </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Infections </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Toxoplasmosis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Others - Echovirus, Leptospirosis, Syphilis, TB, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Varicella </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rubella </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CMV, Coxsackievirus </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hepatitis B (?C), HSV </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Drug-Induced </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">3. Metabolic/Genetic Disorders </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Alpha-1-Antitrypsin Deficiency </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cystic Fibrosis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Dubin-Johnson Syndrome </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Familial Hepatosteatosis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Rotor Syndrome </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Trihydroxycoprostanic Acidemia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Zellweger's Syndrome </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Trisomies 18 and 21 </div> <div> 2. Extrahepatic Obstruction</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1. Infantile Obstructive Cholangiopathy </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Biliary Atresia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bile Plug Syndrome </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Choledochal Cyst </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Choledocholithiasis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">extrinsic bile duct compression </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">spontaneous bile duct perforation </div> <div> 3. Metabolic Disorders</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1. Disorders of Carbohydrate Metabolism </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Hereditary Fructose Intolerance </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Galactosemia-I+III </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Glycogen Storage Diseases - Types I,III,IV,VI,IX </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">2. Disorders of Amino Acid Metabolism </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Tyrosinemia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">3. Disorders of Lipid Metabolism </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Gaucher Disease </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Niemann-Pick Disease </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Wolman Disease </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cholesteryl Ester Storage Disease </div> <div> <B><U>PATHOPHYSIOLOGY:</U></B></div> <div> 1. Bilirubin Metabolism:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">end product of heme degradation </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">majority derived from RBC's </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">8-10 mg/kg/day produced </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1g Hb = 35 mg bilirubin </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">two types: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">unconjugated (indirect) - prehepatic, enterohepatic </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">conjugated (direct) - hepatic </div> <div> 2. Physiological Jaundice:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1. Elevated Bilirubin Load </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">increased RBC volume </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">decreased RBC survival </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">increased enterohepatic circulation </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">2. Decreased Hepatic Uptake of Bilirubin </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">low level of ligandin </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">competition for binding to intracellular proteins </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">3. Defective Bilirubin Conjugation </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">decreased UDP glucuronyl transferase activity </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">4. Defective Bilirubin Excretion </div> <div> 3. Non-Physiological Jaundice:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">see differential diagnosis </div> <div> <B><U>CLINICAL FEATURES:</U></B></div> <div> 1. Physiologic Jaundice</div> <div> 1. Features</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">appears on Day 2 </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">peaks on Days 2-5 </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">disappears after Day 7 (term infants) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">disappears after Day 14 (premature infants) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">of term babies: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">60% are jaundiced within the first week </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">95% have a bilirubin < 260 umol/L </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">visible jaundice occurs at levels > 85 umol/L </div> <div> 2. Non-Physiologic Jaundice</div> <div> 1. Features</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">within 24 hours </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">total bilirubin > 225 umol/L </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">direct bilirubin > 35 umol/L or > 30-40% of total </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">rate of rise > 85 umol/L in a 24 hour period </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">persists > 7 days (term) or > 14 days (preterm) </div> <div> 3. Approach</div> <div> 1. History</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1. Maternal History </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">blood type </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">past obstetrical history </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">abortions (spontaneous or induced) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">jaundiced sibs </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">past medical history </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">IDDM </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">family history </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">inborn errors of metabolism, cystic fibrosis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">congenital hepatic diseases </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">congenital hemolytic anemia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">jaundice, anemia, splenectomy, gallbladder disease </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">2. Pregnancy History </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">complications </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">infections (TORCH), illnesses, PIH, GDM </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">sepsis - premie, fever, increased WBC, PROM, amnionitis, etc </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">3. Labour and Delivery History </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">gestational age - ? premie </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">method of delivery - ? traumatic </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">APGAR or cord gases - ? birth asphyxia </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">ingestion of maternal blood </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">delayed cord clamping </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">4. Post Natal History </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">characteristics of jaundice - ? onset, duration, etc. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">method of feeding - ? breast milk jaundice </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">infants blood group - ? Rh or ABO incompatability </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">evidence of underlying illness: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">delayed passage of meconium, nausea/vomiting, sepsis, </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">failure to thrive, decreased caloric/fluid intake </div> <div> 2. Physical</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1. Vitals </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">temperature (sepsis) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">weight/length (SGA, LGA) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">head circumferance (decreased size with TORCH infections) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">2. HEENT </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">cephalohematoma </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">bruising </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">3. Gastrointestinal </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">hepatosplenomegaly (hemolytic anemia, congenital infections, inborn errors of metabolism) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">mass/distention (obstruction, adrenal hematoma) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">4. Skin </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">plethoric (polycythemia) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">pallor (anemia) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">petchechiae (sepsis, congenital infections, severe hemolytic anemia) </div> <div> <B><U>INVESTIGATIONS:</U></B></div> <div> 1. First Line</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">bilirubin (total and direct) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">blood groups and Rh (mother and infant) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CBC (Hct, Hb, Platelets) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Coombs test </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">peripheral blood smear/morphology </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">reticulocyte count </div> <div> 2. Second Line</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">septic work-up </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">cultures (blood, CSF, urine), chest x-ray </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">screen for hypothyroidism </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">TSH, T4 </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">screen for inborn errors of metabolism </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">urine for organic and amino acids </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">plasma for amino acids </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">alkaline denaturation of Hb test of emesis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">- PT, PTT, haemoglobin electrophoresis </div> <div> <B><U>MANAGEMENT:</U></B></div> <div> 1. Alter Feeding</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">interrupt breast-feeding </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">stimulate enterohepatic circulation </div> <div> 2. Phototherapy</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">based on birth weight and age of patient </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">white or blue lights, single or double bank </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">principle: photoisomerization </div> <div> 3. Exchange Transfusion</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">direct removal of bilirubin </div> <div> 4. Medications</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">phenobarbital trial to induce glucuronyl transferase activity </div> <bR> </NOBR></tD> </tR> </TABLE></div> <bR> </td> </tr></table></body>