Jaundice

CHAPTER 15 Jaundice



David Cartwright, Garry Inglis, Mark Davies



Term newborns


Features to be alert for in term newborns with jaundice are:


• jaundice that is obvious in the first 24 hours of life — measure a total serum bilirubin level (SBR) and look for a specific cause (especially haemolysis)

• a positive Coombs’ test (now called direct antibody test, DAT)

• Rhesus, O–A or O–B incompatibility

• numbers for total SBR to carry in your head to alert you to jaundice that is possibly not physiological and may need further investigation at various ages are:
— 150 μmol/L at 24 hours

— 200 μmol/L at 48 hours

— 250 μmol/L at 72 hours

— 300 μmol/L at any time.

Note: for SBR 1mg/dL ≅ 17 μmol/L.


Investigate babies who need phototherapy:


• Do a ‘haemolytic screen’ which should include:
— full blood count and film with reticulocyte count — for red blood cell (RBC) morphology, pyknocytes, spherocytes, etc, and evidence of RBC turnover

— maternal and baby blood group (if not already known)

— Heinz bodies

— DAT (Coombs’ test)

— glucose-6-phosphate dehydrogenase (G6PD) level.

• Order a conjugated SBR separately if you are concerned.

• Order liver function tests separately if concerned.

Concerns include severe hyperbilirubinaemia, evidence of congenital viral infection, green-looking jaundice, pale stools and dark urine.


• Always measure another total SBR a few hours after a high SBR so that you can gauge the rate of rise (or fall if treated).


Therapy guidelines for term newborns


There are no rigorously tested guidelines for therapy. Consider using Figures 15.1 and 15.2 — they are based on experience rather than any rigid testing scheme or randomised controlled trial.


image

Figure 15.1 Guidelines for phototherapy in infants ≥35 weeks gestational age — if the total SBR plots above the appropriate line, then start intensive phototherapy


SBRtotal = total serum bilirubin level


image

Figure 15.2 Guidelines for exchange transfusion in infants ≥35 weeks gestational age — if the total SBR plots above the appropriate line despite intensive phototherapy, then do an exchange transfusion


SBRtotal = total serum bilirubin level


[These graphs were prepared by using data from: Anonymous. Clinical practice guideline: management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Pediatrics 2004;114:297–316 (erratum appears in Pediatrics 2004;114:1138).]



Low risk: ≥38 weeks gestation and no risk factors.


Medium risk: 35–37+6 weeks gestation and no risk factors; OR ≥38 weeks and risk factors present.


High risk: 35–37+6 weeks gestation and risk factors present.


‘Risk factors: isoimmune haemolytic disease/positive DAT, septicaemia, significant metabolic acidosis, G6PD deficiency, asphyxia, temperature instability, significant lethargy, hypoalbuminaemia.


(DAT = direct antibody test; G6PD = glucose-6-phosphate dehydrogenase)

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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Jaundice

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