CLINICAL LECTUREDEMONSTRATION

NEONATAL JAUNDICE

History

• Thenuka Sathsara

• 1 month and 13days old baby

• Presented with

yellowish discolouration of body

for 3 weeks

(noted since 14days of age)

Antenatal history

• 2nd child of family

• Expected pregnancy

• Taken folic acid after pregnancy was confirmed by urine hcG

• Rubella vaccination-taken

• No maternal infections,rashes

• USS done-12,20,28 wks

no abnomality detected

no oligo or polyhydroamniosis

Postnatal history• EL/LSCS-due to past section• Liquor-clear• Term• BW:3.050kg• Cried at birth.no resuscitation given• No admission to SCBU• Breast feeding established within 1/2hr-good

sucking• During hospital stay,

no jaundice observed,no fits,no hypoglycaemiaor any other blood abnormality

• Discharged within 24hrs after delivery.

At home

• Compared with other child,he is a good baby,notcausing much trouble to mother

• Less active,Sleeping most of time• On & off protruding his tongue out• Feeding-good

good sucking,10-12 times per day,sucking for 15 min at time,no post pandrial vomitinggood UOP 7-8 times per dayweight gain not meassured

At home

• No straining

• No excessive crying while passing urine

• having costipation- bowel opening every 2-3 days(I.O ,Hypothy)

• No pale stools

• No dark urine

• No bleeding from umbilicus

• No umbilical stump infection

• No rashes

• No cantact hx of fever,rash,or any infection in family members during past 1 month

• Blood groups

mother’s O+

Baby’s- not known

• Maternal medical illneses-

no thyroid diseases or symptoms of hypothyroidism

no hepatitis-no maternal blood or plasma transfusion

no STI

• No foreign travels in mother or father

• No risk factors for toxoplasmosis in mother

no pets (cats) at home

not cleaned animal faeces by mother

not walked barefoot outside

not cut & prepared uncooked meat

Health care services

• PHM visists: 5, 14, 21 days

mild jaundice detected at day 14

asked to do proper breast feeding & expose baby to sunlight

-but not responded

• 1st well baby clinic visit-day 37

MO noted jaundice & asked to admit the baby immediately

weight meassured.weight gain was poor

• After that baby got admitted to CSTH

Developmental Hx

• Age appropiate

• Gross motor-can lift chin to 45 degree in prone position

• Fine motor & vision: follow faces midline

• Hearing ,speech language;get frightened to some sounds

coos

• Social;smiles responsively with mother

• Immunisation;BCG at birth.papule has developed

• Dietary hx:

exclussive BF

technique corrected by both lactation centre & PHM

using both sides of breast

changing to other side after emptying one side

• Family hx;

no haematological diseases

no consanguinity

no neonatal jaundice

• PSH• Drug Hx nill• Allery Hx

• Social Hx:mother 30 yrs -house wifefather 30yrs –carpenter(working in somebody else's workshop)

• Monthly income :30 000• elder daughter-3yrs

lives in Nawala with mother’s sister these days

• Home town-Kahathuduwa• Nearest hospital-Wathara• No Vehicle at home

Examination

OFC 37cm(10-20)

Weight 3.45kg(25-50)

Length 52(25-50 )

• Jaundice all over he body including plam & sole

• Lethargic child

• Coarse face

• Aterior fontanella wide open ,>3 finger breath

• Posterior fontanella open ,>1 finger breath

• Sagital suture open >1 finger breath

• No cephalhaematoma

• No pallor

• Eye-icterus

no cataract

• Protruding tongue

• No goiter

• No chest wall deformity

• Lungs clear

• Umbilical hernia • Umbilicus healthy• Abdomen distended• No organomegally• Femoral pulses B/L palpable• Hip subluxation or dislocation• Testis B/L in scrotum• Primitive reflexes present ,but sluggish• Chin lift on supine position• Smile with mother• hypotonic

Summery

• 38 day old baby boy who was born to non consanguinous healthy parents, presented with prolonged jaundice

• Sucking poor• Lethargic• Reduced crying• Poor weight gain• Hx not suggestive of obstructive

jaundice,haemolytic anaemia ,sepsis• Antenatal and perinatal Hx-uncomplicated

Ex

• Jaundice up to sole and palm

• Sutures separated ,widely open fontanella

• 3rd fontanella?

• Eye icteric yellow tinge

• Protruding tongue

• Umbilical hernia

• No organomegally

• Murmur

problem

• Prolonged jaundice

• Delayed diagnosis

• Poor weight gain

• Poor socio economic background

Differential diagnosis

• Hypothyroidism

• Sepsis –UTI

• Congenital infection

• Biliary atresia

INVESTIGATIONS

1) Serum bilirubin levels

Total – 187.4 µmol/l (5-21)

Direct -29.2 µmol/l (0- 3.4)

Indirect – 158.2 µmol/l

Indirect hyperbilirubinaemia

2) Urine for bile - negative

3) FBC

RBC- 4.15 x 10⁶ / µl

Hb -15.7 g/dl

MCV - 110.5

MCH - 37.8

MCHC – 34.2

RDW -14.1

WBC -9.8 x 10³ / µl

Neu – 13.4 %

Lymph -77.3 %

Plt – 214 x 10³ / µl

4) Blood picture

RBC changes are suggestive of liver pathology.

No evidence of haemolysis.

5) Reticulocyte count -1.7 %

6) Blood group – O negative

7) USS Abdomen –

Mild hepatomegaly with increased echogenicity

8) UFR – NL

9) Urine culture – No growth

10) CRP < 6 g/dl

11) C-Xray + Lumbar sacral spine ; AP & lateral - NL

12) TORCH screening – Awaiting ….

13) Liver enzyme –

ALT - 35.8 u/l (10-40)

AST – 69.6 u/l (13-31)

LFT

Albumin -43.6 g/l (30-45)

T. protein - 62.8 g/l (40-80)

APTT - 38 sec (25-40)

14) TFT

FT4 - 0.05 ng/dl (0.89 - 2.2 )

TSH - > 100 µ IU/ ml (0.72 -11 )

Primary Hypothyroidism

MANAGEMENT

• Conservative management

Breast feeding assessment .

EBM – 60 cc 2 hrly .

Daily weight measurement & assess hydration .

Lactulose syrup 2.5 ml tds

• Specific management

Thyroxine – 37.5 µg mane .

Cardiac assessment done .2D Echo –Moderate size PDATwo small ASD sR/V in 3 months / earlier if indicated

Eye referral . USS neck .

• Rpt TFT in 2 wks

Prolonged Jaundice

• Yellowish discoloration of skin, sclera & mucous membrane• Babies become clinically jaundiced when the bilirubin level

reaches 80-120 µmol/L• Prolonged jaundice;

if term baby - > 2 weeks(14 days)if pre term baby- > 3 weeks(21 days)

• Prolonged jaundice;Due to Unconjugated HyperbilirubinaemiaDue to Conjugated Hyperbilirubinaemia

• Unconjugated Hyperbilirubinaemia:-Congenital Hypothyroidism-Infection/sepsis( particularly UTI)-Breast milk jaundice(diagnosis of exclusion)-Persistent Physiological jaundice

high Hb conc. at birth short RBC life span(70 days)less efficient hepatic bilirubin metabolism

-Persisting haemolysis( hereditary spherocytosis, sickle cell anaemia, G6PD deficiency)

-Polycythaemia-Crigler-Najjar syndrome-Extravasated blood- cephalhaematomaInborn errors of metabolism-Galactosaemia

• Conjugated Hyperbilirubinaemia:(>20% of Total bilirubin)

( jaundice+ dark urine, pale stools)

-Biliary atresia

-Neonatal hepatitis syndrome

-Choledocal cyst

-Intrahepatic biliary hypoplasia- Alagille’ssyndrome

Congenital Hypothyroidism

• Reduced Thyroid hormone production in new born

• Profound irreversible mental retardation is the most serious complication which could be minimized if detect early & treat early

• Prevalence 1:4000

• Girls>Boys

• Causes:1) Dysgenesis( commonest-85%)

Absent/ectopic/hypoplasia

2) Dyshormonogenesis-10%

can have goitre at birth

3) Pituitary failure- isolated TSH deficiency is rare

usually associated with panhypopituitarism, which usually first manifests with GH & ACTH deficiency

4) Maternal blocking antibodies

5) Iodine deficiency-commonest cause of congenital hypothyroidism world wide

Presentation

• Infants may be asymptomatic at birth due to transplacental transfer of T4

• Good babies- sleepy, not crying

• Prolonged jaundice

• Constipation

• Coarse facies

• Dry skin

• Large fontanelles-posterior fontanell is >1cm

• Bradycardia

• Hypothermia

• Hoarse cry

• Hypotonia/feeding difficulties

• Lethargy

• Protruding large tongue

• Umbilical hernia

• Goitre-only in minority

Diagnosis

• TFT- do after 1 week of age( to prevent false positive results due to maternal surge of TSH at birth)

-TSH-high(except in pituitary failure)

-T4 –low

• Thyroid scan- US & radio isotope to locate ectopic & to confirm agenesis

• Bone age- less than chronological age(lower femur ossification centre should present at birth)

Epiphyseal dysgenesis

Neonatal Screening

Heel prick test/Guthrie Test:

Around 5-7 days of life

Done in some developed counties to diagnose congenital hypothyroidism early

To detect high TSH levels & low T4 level

If abnormal-needs proper venous sample to confim

Not 100% accurate

Management

• Once diagnosis is suspected;

TREAT URGENTLY, treatment is usually started before 3 weeks of age

• Thyroxine once daily- morning dose, before breakfast

• Start with 10-15µg/kg

• Adjust according to response(clinical & biochemical) to maintain normal growth, TSH & T4

• Life long

• Follow up – monitor the patient clinically & biochemically

• Clinically: linear growth, weight gain, development, any features to suggest hyper/hypothyroidism, overall well being

• Biochemically: T4 & TSH

4-6 weeks after initial treatment

1-3 monthly during first year

2-4 monthly during next year

After 3 years depending on the symptoms & the compliance

• Parental education: life long treatment, complications of poor compliance & proper administration of medication & follow up

• Prognosis: Early detection & treatment prevents severe mental retardation but some may show delay & impairment even after early treatment.

THANK YOU