NOTES
FROM
LECTURE
VERBALIZED
TO
KNOW
FOR
THE
TEST
Newborn
Complications
Hyperbilirubinemia
of
the
Newborn:
know
the
difference
between
-
Physiologic:
normal
for
newborns
-
Onset
>
24
hrs
-
Peaks
3-5
days
-
Pathologic
-
Onset
<24
hours
Physiologic
Jaundice
-
Premature
infants
are
at
higher
risk
-
Visible
when
serum
bilirubin
level
is
>4
to
6
mg/dl
-
Bili
levels
increase
after
birth:
increased
bilirubin
production
and
delayed
elimination.
-
Can
also
be
caused
by
enterohepatic
recirculation
of
bilirubin
-
Bili
levels
decrease
after
the
1st
week
of
life
-
Occurs
>24
hours,
peaks
3-4
days
in
term
neonates
and
5-6
days
in
preterm
neonates
-
Increased
incidence
in
Asian,
Native
American,
Eskimo
Bilirubin
-
From
breakdown
of
RBCs
-
Normal
end
of
life
span
-
Abnormal
lysis
of
RBCs
-
Unbound
bili
(indirect)
can
leave
the
vascular
system
and
permeate
the
skin,
sclera,
oral
mucous
membranes
-
In
the
liver,
unbound
bili
is
conjugated
with
glucuronide
-
Conjugated
Bilirubin
(Direct)-
soluble
and
is
excreted
as
bile
through
action
of
bacterial
flora
-
Conjugation
of
bilirubin
is
process
of
changing
bilirubin
from
fat-soluble
to
water-soluble
product
then
→
excreted
via
urine
&
feces
→
how
baby
will
resume
regular
function
-
If
baby
is
not
eating/feeding
→
they
will
not
be
pooping
-
Urobilirubin
is
excreted
in
urine
and
feces
-
The
normal
newborn
has
higher
Hg/
Hct
for
fetal
circulation-
born
with
extra
RBC’s
→
they
breathe
through
those
red
cells
-
Newborn:
45%
to
61%
Infant:
32%
to
42%-->
This
contributes
to
normal
physiologic
jaundice
in
newborns
-
TSB:
lab
measurement
of
total
serum
bilirubin
(conjugated
and
unconjugated
bilirubin)
Risk
Factors
in
Healthy
Full/Near-Term
Infants
-
Hemolytic
disease-
ABO/Rh
incompatibility
→
if
the
mom
is
Rh
-
OR
O+/O-,
If
mom
is
O,
we
need
to
test
the
baby,
A,
B,
AB
(incompatibility)
-
Rh+
baby
sets
up
a
problem
for
jaundice
-
Polycythemia-
most
babies
are
polycythemic
-
G6PD-
ethnicity,
males:
a
genetic
disorder
that
happens
when
the
body
does
not
have
the
enzyme
G6PD NOTES
FROM
LECTURE
VERBALIZED
TO
KNOW
FOR
THE
TEST
-
Will
appear
normal
at
birth
-
May
experience
neonatal
jaundice
and
hemolysis
-
Can
cause
neurologic
damage
or
even
death
-
Dehydration,
poor
feeding
→
weight
that
babies
lose
in
5
days
(10%),
if
baby
lost
over
10%-->
sets
them
up
for
worsening
jaundice
Risk
factors
for
Hyperbilirubinemia
-
Increased
production
of
bilirubin–
breaking
down
extra
RBCs
-
ABO
incompatibility,
bruising,
cephalohematoma,
delayed
meconium
passage,
prematurity/SGA
-
Altered
hepatic
clearance
of
bilirubin-
septic
baby
→
further
risk
for
jaundice
-
Sepsis,
asphyxia/hypoxia,
hypoglycemia,
hepatitis
-
Birth
injury
Assess
the
level
of
jaundice
-
First
noticeable
in
the
head-
sclera,
mucous
membranes
-
Touch
finger
to
forehead
→
blanching,
if
there
is
a
yellow
tint=jaundice
-
Then,
thorax
&
abdomen
-
Then
extremities,
lower
legs
-
All
newborns
are
assessed
whether
visible
jaundice
or
not
Transcutaneous
Bilirubin
Monitor:
new
monitors
are
accurate
within
2-3
mg/dl
at
serum
levels
-
Checked
on
all
newborns
-
Not
a
useful
tool
after
phototherapy
has
started
→
use
TSB
-
Normal
unconjugated=
0.2-1.4
-
Use
normogram-
age
in
hours
related
to
level
of
bili
-
High
TCB
→
do
a
lab
(TSB)
Serum
Bilirubin
(TSB)
-
Which
is
more
accurate?
TCB
or
TSB
:
TSB
is
more
accurate
-
Bili
tool:
date
&
time
of
birth
&
total
bilirubin:
program
that
determines
risk
factors
for
jaundice
Bhutani
Graph:
age
of
baby
in
hours
vs.
TSB:
tells
the
risk
zones
Important
Factors:
NOT
just
the
numbers!!
-
Timing
of
onset
-
Gestational
age NOTES
FROM
LECTURE
VERBALIZED
TO
KNOW
FOR
THE
TEST
-
Age
in
hours
since
birth
-
Maternal
blood
type
&
Rh-ABO
incompatibility
-
Hx
of
sibling
with
hyperbilirubinemia
-
Evidence
of
hemolysis
-
Infants
Physiologic
status-
sepsis
-
Progression
of
serial
serum
bilirubin
levels
-
3-day-old
baby,
bilirubin
of
13.5
(low-risk
zone)
Jaundice
&
Breast
Milk
-
Breastfeeding
jaundice
-
After
24
hrs
-
Related
to
inadequate
intake
-
Dehydration
-
Resolves
with
increased
intake
-
Breast
Milk
Jaundice
-
Later
onset
after
first
week
of
life
-
Attributed
to
increased
enterohepatic
circulation
-
May
be
unidentified
factors
in
breastmilk
interfering
with
bilirubin
metabolism,
causing
an
exaggerated
physiologic
jaundice
-
Inadequate
intake
which
leads
to
dehydration
and
sometimes
hypernatremia
-
Persists
more
than
2
weeks
-
May
be
necessary
to
interrupt
breastfeeding
to
resolve
Pathologic
Jaundice
-
Bilirubin
increase
begins
in
the
first
24
hours
-
Persists
beyond
day
7
(term)
and
10
(preterm)
-
Total
bilirubin
>12
mg/dL
in
bottle-fed
-
Total
bilirubin>
14mg/dL
in
breastfed
-
Total
bilirubin
>
15
mg/dL
in
preterm
-
5-11%
of
infants
will
develop
severe
hyperbilirubinemia
Pathologic
Jaundice
-
Casual
factors:
-
ABO
incompatibility,
Rh
Sensitization,
and
hemolytic
disease
of
the
newborn
-
S&S
pathologic
hyperbilirubinemia:
-
Jaundice,
elevated
serum
bili
levels,
enlarged
liver,
poor
muscle
tone,
lethargy,
poor
sucking
reflex
-
Assessment:
head
to
toe
jaundice
level,
sclera
Treatment
for
Jaundice:
-
hydration/frequent
breastfeeding-
increase
stools
-
Depends
on
the
extent
of
hemolytic
process
and
underlying
cause
-
Intravenous
gamma
globulin
for
isoimmune
etiology
-
Prevention
is
best
(Rhogam)
-
In
utero
transfusions
for
isoimmunization
-
3
variables
taken
in
account:
age,
bili
levels,
and
weight:
plotted
on
graph
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