Issues in a Newborn: Jaundice and Beyond

heme, biliverdin, unconjugated, liver, intestine, stercobilins, stool

Jaundice: Background

-Bilirubin produced by breakdown of ____ → iron and _________ → biliverdin converted to ____________ bilirubin by bilirubin reductase → carried to _____ and conjugated → excreted in bile to _________ → metabolized by gut flora to _________ → excreted in _____

stasis, glucuronidase, unconjugated, liver, 5, total, 5, first, 13-15

Neonatal Jaundice: Continued

-Newborns have _______ of conjugated bilirubin → broken down by mucosa beta ________________ → ____________ bilirubin → resorbed and taken to _____

-Physical evidence of jaundice in newborn wen bilirubin _-10 mg/dL. If jaundice, send for ______ bilirubin 

-Bilirubin >_ mg/dL on ______ day of life or > ____-___ mg/dL thereafter needs further workup 

• Indirect and direct bilirubin plus total, blood typing, Coombs test, CBC with smear, reticulocyte count, serum albumin, G6PD test 

jaundice, Rh, spherocytosis, breast milk, atresia

Differential Diagnosis of Neonatal Hyperbilirubinemia

-Unconjugated/Indirect Hyperbilirubinemia

• Physiologic ________

• Hemolytic disease → ABO or __ incompatibility

• Structural or metabolic abnormality of RBCs → hereditary ____________ or G6PD deficiency

• Hereditary defects in bilirubin conjugation → Crigerl-Najjar or Gilbert Disease

• Bacterial sepsis

• ______ _____ jaundice

-Conjugated/Direct Hyperbilirubinemia

• Biliary ______

• Extrahepatic biliary obstruction

• Neonatal hepatitis

• Alpha-antitrypsin deficiency

• Neonatal hemosiderosis

bilirubin, mass, flora, motility, 24, 3-5, 15, 2

Neonatal Jaundice: Physiologic Indirect / Unconjugated Hyperbilirubinemia

-Etiology

• Increased _________ production due to increased RBC _____, shortened RBC life span

• Hepatic immaturity

• Lack of gut _____

• Slow intestinal _________

-Characteristics

• Appears after __ hours of life

• Peaks around ___-___ days of age, rising < 5 mg/dL/day

• Total bilirubin typically no more than __ mg/dL

• Resolves within 1 week in term infants and _ weeks in preterm infants

24, more, 2, anemia

Neonatal Jaundice: Pathologic Indirect / Unconjugated Hyperbilirubinemia

-Evident before __ hours of life, usually indicative of hemolysis

-Bilirubin level increases _____ than 0.5 mg/dL/hr

-Peak bilirubin is > 13-15 mg/dL in term infants 

-Appears or increasing after _ weeks of life

-Hepatosplenomegaly present

-_______ present 

elevated, Rh, negative, G6PD, normal, obstruction, Gilbert

Neonatal Jaundice: Pathologic Indirect/Unconjugated Hyperbilirubinemia

-Increased bilirubin production: Hemolytic (reticulocyte count ________)

• Immune-mediated (Coombs positive) → ABO/__ incompatibility 

• Non-immune disease (Coombs _______) → ____ deficiency, spherocytosis 

• Bacterial or viral sepsis 

-Increased Bilirubin production: reticulocyte count _______

• Hemorrhage, polycythemia, bowel __________, breast feeding jaundice 

-Decreased rate of conjugation 

• Crigler-Najjar Syndrome (rare, severe) → autosomal recessive or dominant, causes a deficiency in glucuronyl transferase 

• ________ Syndrome (more common, mild) → mutation in promotor region of glucuronyl transferase 

• Hypothyroidism

not, calories, increased, first, 3rd, glucuronidase, conjugation, second, stop

Neonatal Jaundice: Related to Breast Feeding and Milk

-Breast Feeding Jaundice

• Etiology → baby is ___ nursing well and not getting enough ________, leading to __________ reabsorption of bilirubin in intestines

• Characteristics → appears in the _____ days of life, usually disappears by the ___ week of life, and very rare to cause complications

-Breast Milk Jaundice

• Possible Etiology → breast milk contains ____________, which inhibits __________ of bilirubin

• Characteristics → appear during ________ week of life, can last for several weeks

• Monitor bilirubin

• Can ____ breast feeding for 1-2 days to allow levels to decrease

unconjugated, CNS, brainstem, metabolism, death, duration, term, 35

Bilirubin Encephalopathy / Kernicterus: Background

-Elevated levels of __________ bilirubin is toxic to the ___

• Deposits in brain cells (basal ganglia and _________ nuclei)

• Impairs energy ___________ of the cell and causes cell ______

-Risk depends on _______ of hyperbilirubinemia, concentration of serum albumin, associated illness

-Not typically seen in ____ infants with bilirubin levels < 20-25 mg/dL

-Highest incidence in term infants at levels > __ mg/dL

feeding, cry, hypertonicity, upward, deafness, palsy

Bilirubin Encephalopathy / Kernicterus: Symptoms

-Early Symptoms

• Lethargy, poor ________, hypotonia, irritability, high pitched ___, jaundiced 

-Late Symptoms 

• _____________ (arching of neck and trunk), gaze abnormality (paralysis of _______ gaze), seizure/coma 

-Possible Permanent Disability 

• Mental retardation, _____________ or other auditory disturbances, enamel dysplasia of teeth, cerebral ______

16-18, indirect, excreted, high, kernicterus

Neonatal Jaundice: Treatment

-Phototherapy → started at bilirubin levels between ____-____ mg/dL in term infants

• Light absorbed by ______ bilirubin in skin and converted to a water soluble form and __________

-Exchange transfusion → indicated in dangerously ____ bilirubin levels

• Levels rise despite phototherapy

• Those at risk for ____________

• Phototherapy and albumin given pending exchange

2, not, CMV, bile, metabolism

Neonatal Jaundice: Pathologic Direct / Conjugated Hyperbilirubinemia

-Direct bilirubin > _ mg/dL or > 20% of total bilirubin

-Indicates serious underlying disorder but is ___ neurotoxic

-Etiology → ___ infection, hepatitis, sepsis, thickened _____ from prolonged hemolysis, hyperalimentation cholestasis, biliary atresia, cystic fibrosis, inborn errors of __________

-Evaluation → LFTs, bacterial/viral cultures, metabolic screening tests, hepatic US, sweat chloride

>, 37, group B, 7, vertical, >, horizontal

Neonatal Sepsis: Background

-Risk Factors → maternal intrapartum temperature > 38 C, membrane rupture > 18 hours, delivery at < __ weeks gestation, chorioamnionitis, and maternal _____ _ streptococcal colonization

-Early onset sepsis → symptoms < _ days of age (within 72 hours and often within 24 hours)

• _________ transmission (contaminated amniotic fluid, bacteria in mothers genital tract)

-Late onset sepsis → symptoms _ 7 days of age 

• Vertical transmission or ___________ transmission 

Group B strep, E. coli, staph aureus

What are the three most common bacterial agents causing neonatal sepsis in term infants?

distress, vomiting, cyanosis, diarrhea

Clinical Findings in Neonatal Sepsis

-Hyperthermia

-Respiratory _______

-Tachycardia

-Lethargy

-Poor feeding

-Apnea

-Bradycardia

-Poor perfusion/hypotension

-___________

-Jaundice

-Hepatomegaly

-__________

-Hypothermia

-Irritability

-Seizures

-Abdominal distention

-___________

culture, low, elevated, urine

Neonatal Sepsis: Evaluation

-Full physical

-Blood ________ (diagnosis confirmed by positive blood culture)

-LP (meningitis)

-CBC w/ diff → ___ WBC count, neutropenia, elevated ratio of immature to mature neutrophils

-CXR → pneumonia common in early onset

-CRP and/or procalcitonin → _________

-_____ culture (infants > 7 days old)

-Other culture

ill, ampicillin, gentamicin, hypoglycemia

Neonatal Sepsis: Treatment

-Initial treatment → empiric antibiotics

• Indicated in ___ appearing infants, concerning symptoms (temp instability, resp/cardio/neuro sx), CSF WBC count > 20-30 cells, confirmed or suspected maternal chorioamnionitis, high sepsis risk

• _________ and __________ (preferred) or 3rd generation cephalosporin

-Other treatment → maintain adequate oxygenation and perfusion, prevent ____________ and metabolic acidosis, maintain normal fluid and electrolyte status, and pathogen specific therapy once cultures are back

stillbirth, preterm, withdrawal, sleep, irritability, replacement

Maternal Drug Use

-Cocaine/Meth

• Can lead to _______, IUGR, placental abruption, and ________ delivery 

• Symptoms → no specific __________ syndrome. Some irritability, tremor, increased stress response may be seen 

-Opiates 

• Symptoms → poor feeding, poor _____, fever, diaphoresis, tremors, seizures, emesis, diarrhea, _________ (withdrawal) 

• Treatment → decrease stimulation, ____________ doses of narcotic then wean, and phenobarbital if seizures 

teratogenic, withdrawal, short, upper, optic, IUGR, SIDS

Maternal Drug/ETOH Use

-Alcohol → _________

• Affects fetal growth and development

• Can experience __________ similar to opioid use

-Fetal Alcohol Syndrome

• _____ palpebral fissures, thin _____ lip, flattened philtrum, growth deficiency, microcephaly, partial or complete agenesis of corpus callosum, _____ nerve hypoplasia, hypotonia, and poor feeding

-Tobacco Smoking

• Effects fetal growth (____)

• Increased risk of preterm labor and _____

• May show irritability, hypertonicity, hyperexcitability, and tremors

-Marijuana

• Not teratogenic, can cause neurodevelopmental problems, rarely requires treatment