Case Presentation 140711

8/11/2019 Case Presentation 140711

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Case

CC: 5 day old female admitted from PMDs office 2 o to

TSB of 19.3 @ routine f/u visit.


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Bilirubin in Adults vs. Newborns

All term/near-term neonates have > 1 mg/dLTSBBilirubin production is 2-3 times greater than

adultsNewborns have more RBCsRBC life span is shorter (~85 days)

Decreased clearance@ 7 days old, only have 1% of the UGT enzymeactivity of an adult

Increase in enterohepatic circulation

Context: Hyperbilirubinemia for a 5 day old infant is ~17.5


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HPITerm infant born on Friday via SVD to a G1P0P1 motherwho was sero (-) with B+ blood type.Apgars were 7 and 8. BW was 2788g (6 lbs 2 oz).On Saturday (6/28), was discharged, but had difficulty

latching.Baby eats >10x/day , had 1 very small BM since Saturday,lots of gas and has wet diapers regularly.Noticed babys eyes were yellow and the skin was yellow on

Saturday prior to D/C and has not subsided since.Baby did not receive the hepatitis B vaccine at birth, but themother says that she has discussed a plan with the babyspediatrician.


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ROS: (+) irritable night before admission, flatulence(-) rash, congestion, runny nose, cough, fever, vomiting, andsick contacts.

PMH: NKDA. Did not receive Hepatitis B vaccine. PMD is Dr.Underwood.

Social Hx: Lives with two moms, 9.5 yo biological sister, and 21 yo sister.Dad was a donor. No one smokes in the house. There are three

dogs that live in the house.FHx:

Mother denies any hx of jaundice in siblings or relatives. Noother pertinent family history.


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PE

Vitals @ admit: HR: 142 RR: 36 Temp: 98.4 BW: 2.5kg(-10.7%)General: vigorous and responsiveSkin: Jaundice to the groinHEENT: scleral icterusCV: No murmurs, gallops, thrill. Equal femoral pulsesResp: CTAB

Abd: Soft without massesGU: normal appearing femaleNeuro/Neck/Ext: unremarkable


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DDx for Jaundice Tbili Drugs Ceftriaxone

Sulfa drugs

Indirect bilirubin Direct bilirubin

Production Clearance Enterohepatic Circ

Hep. Obstruction Infections Metabolic Diseases

Ordering a TSB, get a direct and total bilirubin


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Ig Class IgM IgM IgG

*B/O Incompatability =Thrombocytopenia

Cause # 1: Increased Production of Bilirubin


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Cause #2: Decreased Clearance

Crigler-Najjar SyndromeGilbert SyndromeMaternal diabetes

Congenital hypothyroidism


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Cause #3: Enterohepatic Circulation


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Cause #3: Increased enterohepatic circulation

Breast milk jaundice (~2%)Physiologic jaundice after first week of lifeBegins after first 3-5 days of lifeUsually resolves by 12 weeks of life

Breastfeeding failure jaundiceFailure to initiate appropriate lactationUsually presents within first week of life

Intestinal obstruction


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Assessment of Bilirubin


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Vocab

Jaundice: physical findingUnreliable in determining the bilirubin levelDocumented as how far it extends

Ex: Jaundice to the chest TcB: Total transcutaneous bilirubinTSB: Total serum bilirubin


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Risk FactorsPredischarge TSB/TcB in high risk zoneABO incompatibilityExclusively breastfedSibling that needed phototherapyGestational age < 38 weeksJaundice before dischargeG6PD DeficiencyAsphyxiaSignificant lethargyTemperature instabilitySepsisAcidosis

Low Risk = Term infant w/o risk factorsIntermediate Risk =

1) Term infant w/ risk factors2) Late pre-term w/o risk factors

High Risk = Late pre-term w/ risk factors


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Bilirubin Nomogram


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Our Baby

Bili peaks around day 4. Must follow -up


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Treatment and Monitoring


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Before Initiating Treatment...

Is the baby feeding?

If BW drops > 12%, or evidence ofdehydration, recommend formula orexpressed breast milk


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Phototherapy

Usually first line treatment after feedingencouragementSpecial blue lightUnder light as much as possible

Needs to be as close to naked as possibleMake sure glasses stay onInitiation of therapy depends on risk stratification


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Initiation of Phototherapy

12

8


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Monitoring after PhototherapyInitiation

Feed every 2-3 hoursIf TSB 25, repeat TSB w/ i 2-3 hours

If TSB 20-24, repeat w/i 3-4 hrs

If TSB


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Exchange Transfusion

Indications:Intensive phototherapy failsJaundice + signs of bilirubin-induced neurologicaldysfunction

Most expensive and time consuming optionMost effective methodMortality: 0.3% (1985 study)Complication rate: ~1%

thrombocytopeniahypocalcemiametabolic acidosis


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Initiation of Exchange Transfusion

19

16.5


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Isoimmune Hemolytic Disease Special circumstance May not improve with phototherapy Treat with IVIg

(0.5-1g/kg over 2 hours) Can repeat in 12 hours, if needed IVIg has shown to decrease need for exchange

transfusion


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Case Conclusion

Phototherapy was started soon after admissionBaby was fed via EBM throughout the night AM TSB = 13.4PE: Scleral icterus. Otherwise unremarkableMom was issued a breast pump to ensure adequatefeedsBaby was discharged

later that day


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References

Wong,RJ; Bhutani, VK. Pathogenesis and etiology ofunconjugated hyperbilirubinemia in the newborn. In:UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessedon June 26, 2014.)

Wong,RJ; Bhutani, VK. Treatment of unconjugatedhyperbilirubinemia in term and late preterm infants. In:UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessedon June 26, 2014.)

American Academy of Pediatrics. (2004). Management of

hyperbilirubinemia in the newborn infant 35 or more weeks ofgestation. Pediatrics , 114, 297-316http://www.gestaltreality.com/2013/09/21/metabolic-

cholestatic-pruritus/

Case Presentation 140711

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