Neonatology Book

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Nonphysiologic Neonatal Jaundice

Aka: Nonphysiologic Neonatal Jaundice, Non-physiologic Neonatal Hyperbilirubinemia, Severe Neonatal Hyperbilirubinemia, Severe Neonatal Hyperbilirubinemia Risk Factor
  1. See Also
    1. Neonatal Jaundice
    2. Risk Score for Neonatal Hyperbilirubinemia
    3. Nonphysiologic Neonatal Jaundice
    4. Breast Feeding Problems for the Infant
    5. Acute Bilirubin Encephalopathy
    6. Chronic Bilirubin Encephalopathy (Kernicterus)
    7. Neonatal Bilirubin
    8. Phototherapy
    9. Exchange Transfusion in Newborns
  2. Criteria
    1. Neonatal Jaundice in first 24 hours of life
    2. Serum Bilirubin rises > 5 mg/dl in the first 24 hours
    3. Direct Bilirubin (conjugated) >2mg/dl
    4. Term Infant
      1. Serum Bilirubin >17 mg/dl
      2. Neonatal Jaundice persists longer than 1 week
        1. Exception: Breast Feeding Jaundice may persist >1 month
    5. Preterm Infant
      1. Serum Bilirubin >15 mg/dl
      2. Jaundice persist longer than 2 weeks
        1. Exception: Breast Feeding Jaundice may persist >1 month
  3. Causes
    1. See Neonatal Jaundice Causes
  4. Risk Factors: Severe Hyperbilirubinemia (Infants 35 weeks gestation or further)
    1. Major risk factors
      1. Jaundice in first 24 hours (always pathologic)
      2. ABO or Rh incompatibility and positive Coombs test (Hemolytic Anemia)
      3. G6PD Deficiency
      4. Delivery at 35 to 36 weeks gestation or earlier Gestational age
      5. Significant Birth Trauma
        1. Cephalohematoma
        2. Large hematomas or significant Bruising
      6. Weight loss >8-10%
      7. Infant Breast feeds only (especially before milk let-down occurs)
      8. East Asian or Native American ethnicity
      9. Family History of sibling who required Phototherapy for Neonatal Jaundice
      10. Serum Bilirubin in high risk range for age in hours
    2. Minor risk factors
      1. Male gender
      2. Maternal age over 25 years old
      3. Maternal Gestational Diabetes and Fetal Macrosomia
      4. Delivery at 37 to 38 weeks gestation
      5. Serum Bilirubin in intermediate range for age in hours
      6. Low birth weight
    3. Other risk factors
      1. Polycythemia
      2. Medication exposure
        1. Mother: Diazepam, Oxytocin
        2. Infant: Pediazole, Chloramphenicol
  5. Signs
    1. Prematurity
    2. Small for Gestational Age
      1. Polycythemia
      2. Intrauterine Growth Retardation (TORCH Infection)
    3. Microcephaly
      1. Intrauterine Growth Retardation (TORCH Infection)
    4. Extravascular blood
      1. Bruising
      2. Cephalohematoma
    5. Pallor
      1. Hemolytic Anemia
      2. Extravascular blood loss
    6. Petechiae
      1. Congenital infection (TORCH Infection)
      2. Sepsis
      3. Erythroblastosis Fetalis
    7. Hepatomegaly or Splenomegaly
      1. Hemolytic Anemia
      2. Congenital infection (TORCH Infection)
      3. Liver disease
    8. Omphalitis
    9. Chorioretinitis
      1. Congenital infection (TORCH Infection)
    10. Hypothyroidism signs
  6. Labs
    1. All patients: Total Bilirubin
      1. Total Bilirubin (Serial values; for recommended interval see Phototherapy)
      2. See Neonatal Jaundice for screening indications
      3. See Risk Score for Neonatal Hyperbilirubinemia
    2. All patients on or at risk for Phototherapy
      1. Precautions
        1. Labs are normal in 88% of infants undergoing Phototherapy
        2. Consider labs if additional risks
          1. Jaundice onset in first 48 hours of life and requires Phototherapy
          2. Hyperbilirubinemia not responding normally to Phototherapy
      2. Complete Blood Count with platelets
      3. Peripheral Smear
      4. Coombs Test
      5. Conjugated Bilirubin (Direct Bilirubin)
      6. Blood Type
        1. Rhesus Incompatibility (CDE)
          1. anti-D (most severe)
          2. anti-C
          3. anti-E
        2. ABO incompatibility
          1. A hemolysins
          2. B hemolysins
        3. Anti-Duffy
        4. Anti-Kell
    3. Severe Hyperbilirubinemia (e.g. on or at risk for exchange transfusion)
      1. Reticulocyte Count
      2. G6PD Enzyme activity level
    4. Increased Direct Bilirubin (Conjugated Bilirubin) >20%
      1. Urinalysis and Urine Culture
      2. Neonatal Sepsis evaluation
    5. Prolonged Jaundice >3 weeks
      1. Consider Breast Milk Jaundice (especially if well appearing)
      2. Direct Bilirubin (if >20%, see above evaluation for infection)
      3. Newborn Screen result focused review
        1. Thyroid Stimulating Hormone
        2. Galactosemia Screen
  7. Evaluation
    1. Term newborn with Jaundice onset Day 1 or after Day 14
      1. See Neonatal Jaundice Causes
    2. Term newborn with Jaundice onset 1 to 14 days of life
      1. Conjugated Bilirubin >2 mg/dl
        1. Suggests biliary obstruction
        2. See Direct Hyperbilirubinemia
        3. See Neonatal Jaundice Causes
      2. Increased Hemoglobin
        1. Polycythemia
      3. Abnormal Peripheral Smear
        1. Observe for Hemolytic Anemia
      4. Normal Peripheral Smear
        1. See Neonatal Jaundice Causes
        2. Consider decreased conjugation causes
        3. Consider non-hemolytic increased Bilirubin load
  8. Resources
    1. Bilirubin Tool
      1. http://www.bilitool.com
    2. Fpnotebook - Newborn Hyperbilirubinemia
  9. Management
    1. See Phototherapy for indicatiions
    2. See Exchange Transfusion for indications in severe Hyperbilirubinemia
  10. Complications
    1. Congenital Anemia (Mild Hemolysis)
      1. Pale
      2. Hemoglobin of 13 to 15
      3. Few Reticulocytes
      4. Slight Hepatomegaly and Splenomegaly
      5. No Urobilinogen
    2. Icterus Gravis (Severe Hemolysis)
      1. Jaundice at birth
      2. Anemia
      3. Large Hepatomegaly and Splenomegaly
      4. Urobilinogen positive
    3. Bilirubin Encephalopathy
      1. Acute Bilirubin Encephalopathy
      2. Chronic Bilirubin Encephalopathy (Kernicterus)
  11. References
    1. (2004) Pediatrics 114(1): 297-316 [PubMed]
    2. (2001) Pediatrics 108(3):763-5 [PubMed]
    3. Moerschel (2008) Am Fam Physician 77:1255-62 [PubMed]
    4. Muchowski (2014) Am Fam Physician 89(11): 873-8 [PubMed]
    5. Porter (2002) Am Fam Physician 65(4):599-614 [PubMed]

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