05 Neonatal Jaundice

Overview

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• Prehepatic: mostly unconjugated

  • Hemolysis: coombs, G6PD, pyruvate etc.

  • Hemorrhage: cephalohematoma

  • Neonate: also twin-twin transfusion

  • Breast milk, breast feeding

• Posthepatic: mostly conjugated. Usually means gallstones/cancer in adults but not in kids

  • Biliary atresia

  • Sepsis

  • Metabolic derrangements

• Intrahepatic: mixed picture. Genetic diseases

  • Criglar Najar: looks like prehepatic

  • Gilbert: looks like prehepatic

  • Dubin Johnson: looks like post hepatic

  • Rotor: looks like posthepatic

  • Hepatitis: damage to liver

Bilirubin

D. Bilirubin

Direct bilirubin aka conjugated:

• has charge, water soluble, cannot cross cell membrane

• when excreted in urine: trapped in urine, turn urine dark

• cannot cross BBB: no kernicterus

Indirect Bilirubin

Indirect bilirubin aka unconjugated:

• fat soluble. Not cross glomerulus and not excreted in urine

• Does not turn urine dark

• Can cross BBB: kernicterus

Jaundice

Physiologic jaundice

Overwhelming normal system with rate limiting conjugation. Takes time to develop. By the time for first visit, not yellow anymore

• onset: after 72 hours. Leaves newborn nursery, turn yellow

• resolution: < 1wk. < 2 wk for premature

• bilirubin: unconjugated

• rise: < 5 / day

Pathologic Jaundice

Atresia, sepsis, metabolic problems. Something is wrong

• onset: first day

• resolution: won't resolve by self

• bilirubin: conjugated

• rise: > 5 / day

Treatment

Only works for unconjugated bilirubin. For physiologic jaundice, help baby move bilirubin along. Pathologic jaundice requires surgery.

• High bili: convert unconjugated to conjugated via blue box

• Really high bili: exchange transfusion

Work up

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Breast Feeding

• path: low quantity, bowel function low, bilirubin sits in colon and reabsorbed

• pt: day 1-7, unconjug bili

• treatment: feed more

Breast Milk

• path: enzyme in maternal milk inhibits conjugation

• pt: > day 7, unconjug bili

• treatment: hydrolyzed formula