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Resident Teaching Sessions in Neonatology
Case – The Jaundiced Infant
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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
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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?
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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)
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case – Question 2
• What would you look for on examination of the infant?
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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
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case – Question 3
• What would be your first line of investigations?
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case – Answer 3
• CBC, diff, film• Bilirubin (unconjugated, conjugated)• Glucose, lytes• Blood culture• Blood group and Coombs test
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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
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Coombs test
• Direct: detects antibodies on the patient’s cells.
• Indirect: detects antibodies in the patient’s serum
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case – Question 4
• What management would you institute immediately?
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case – Answer 4
• Phototherapy• Optimise fluid intake (oral/nasogastric/IV)• Antibiotics• Repeat bilirubin in 4 hours
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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
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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?
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case – Answer 5
• Exchange transfusion:– “Double volume” 160 cc/kg, removes 80% of
red cells, 50% bilirubin
• Intravenous immunoglobulin
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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?
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case – Answer 6
• Complications– Rebound hyperbilirubinemia – Anemia– Manifested as lethargy, poor feeding, poor
growth
• Hct prior to discharge, continue to monitor bilirubin
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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
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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
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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
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Learning Objectives
• Describe the management of the infant with unconjugated hyperbilirubinemia
• List the common causes of unconjugated and conjugated hyperbilirubinemia in the newborn period
