Good Morning!

1. Good Morning! July 19, 2012

3. Semantic Qualifiers

5. Illness Script • Predisposing Conditions • Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc) • Pathophysiological Insult • What is physically happening in the body, organisms involved, etc. • Clinical Manifestations • Signs and symptoms • Labs and imaging

6. Predisposing Conditions Physiologic Jaundice** • Newborns in first full week of life…almost universal • Sibling with history of jaundice/requiring phototherapy • Asian ethnicity • Prematurity • Maternal diabetes • Breastfed infants** • Breast feeding is the most common cause of exaggerated unconjugated hyperbilirubinemia** • Breastfeeding (1st week), Breast milk (6-14 days)**

7. Pathophysiology** Physiologic Jaundice

8. Clinical Manifestations Physiologic Jaundice • Peak bilirubin concentration at 3-5 days • Breast milk jaundice can persist for 1-3 months • Jaundice • Serum bilirubin concentrations of >4-5mg/dL in infants • >2-3mg/dL in older children • Scleral icterus • Elevated total bilirubin • Unconjugated hyperbilirubinemia • NOT conjugated/direct hyperbilirubinemia** • >2mg/dL direct or >20% total bilirubin level • This is PATHOLOGIC

9. Evaluation • After birth, infants should be assessed for jaundice every 8-12h (at least TcB) • Plot to determine what “risk-zone” • Obtain serum measurement if elevated • When to do more tests** • Jaundice in first 24 hours • Any infant receiving phototherapy • When TSB crosses percentiles on the nomogram • What tests • CBC with smear, reticulocyte count, Coombs test** • To detect hemolytic disease (ABO/Rh incomp, G6PD, etc.)** • Direct bilirubin concentration

10. Screening Prior to Discharge**

11. **Sepsis/UTI, metabolic disorders, and endocrine disorders can cause hyperbili…indirect or direct and should be screened for if clinically indicated!

12. Management • Helping mother’s breastfeed appropriately can decrease the likelihood of severe hyperbili** • Every 8-12 hours • Typically feed through breast milk/breastfeeding jaundice unless diagnosis in question or clinical reason not to!** • Lactation consultation when needed • Phototherapy** • Initiation based on TSB and age in hours** • Converts bilirubin into a water-soluble compound that can be excreted in urine or bile without conjugation • Blue lights in 460-490nm wavelength • More exposure = better • Expect a decrease of 0.5mg/dL/hr in first 4-8 hours • NOT for direct hyperbili (bronze infant syndrome) • Exchange transfusion

13. Phototherapy

14. Exchange Transfusion

15. Importance • Bilirubin crosses the BBB if unconjugated and unbound to albumin • Acute bilirubin encephalopathy** • Phase 1: first 1-2 days; poor suck, high-pitched cry, stupor, hypotonia, seizures • Phase 2: middle of 1st week; hypertonia of extensor mm, opisthotonus, retrocollis, fever • Phase 3: after 1st week; hypertonia • Kernicterus** • 1st postnatal year: hypotonia, delayed motor skills • Later: choreoathetotic cerebral palsy, dental dysplasia, sensorineural hearing loss, cognitive impairment

17. Biliary atresia • Progressive and destructive inflammatory process that affects the extra and intra-hepatic biliary tree • Presentation** • Typically well-appearing • Jaundice 1-2 weeks after birth • Elevated direct bilirubin with mild elevation of total bilirubin (typically <12) • Increase AP or GGT • Imaging** • Abdominal US • HepatobiliaryScintiscanning • Kasai Procedure*

18. Noon Conference Fever without a source, Dr. Hescock