Australian Doctor 8th Dec 2023 8th Dec 23 | Page 31

HOW TO TREAT 31
ausdoc . com . au 1 DECEMBER 2023

HOW TO TREAT 31

SBR by 34μmol / L or more , and less
than 1 % by 50μmol / L or more . The
study team therefore recommended clinical SBR correlation testing for infants when sternal TCB measurements are within 50μmol / L of the SBR nomogram phototherapy treatment level . Other groups have similarly recommended clinical TCB /
Chardot C / CC BY 2.0 / bit . ly / 3xVu06L
therapeutic benefits for each patient .
Treatment of underlying aetiology
In conjunction with jaundice-specific
treatment , treat any identified underlying aetiologies , comorbidities or risks . Jaundiced babies often
SBR correlation rules such as meas-
require feeding support via engage-
urement of a serum sample when
ment of allied healthcare profession-
the TCB is within 50μmol / L ( about
als such as lactation consultants and
3mg / dL ) of the local nomogram phototherapy threshold . 72 Clinical practice recommendations such as
child health nurses . Contact local paediatric services to discuss management as necessary .
these can substantially reduce the need for neonatal blood sampling while safely managing the risk of
GP management
The GP management of neonatal
neonatal hyperbilirubinaemia . 73-76 In regard to clinical monitoring of a baby ’ s response to phototherapy , use TCB with caution because
jaundice appears in figure 10 .
PROGNOSIS
THE literature reflects that there are
of the change in dermal bilirubin
wide variations in the categorisation
during treatment . Most guidelines advise against TCB measurement
Figure 5 . Biliary atresia .
and definitions of neonatal hyperbilirubinaemia and associated long-
after phototherapy for at least
term neurodevelopmental sequelae .
24-48 hours after phototherapy has been ceased . 77-81
Additional blood investigations
Suggested additional blood investigations
to consider include conjugated bilirubin , blood group , blood film , direct antiglobulin test ( DAT ), G6PD assay and FBC . LFTs and thyroid function tests are also suggested for babies with prolonged jaundice ( longer than two weeks ), in addition to any other relevant investigations relating to the infant ’ s presentation such as investigations for possible sepsis or a metabolic disorder .
Emerging neonatal jaundice assessment technologies
The ideal neonatal jaundice meas-
CHD = common hepatic duct , LHD = left hepatic duct and RHD = right hepatic duct .
Drriad / CC BY-SA 3.0 / bit . ly / 3Fm49Ja
Despite this , it is clear that cases of kernicterus still occur , particularly in resource-limited , low-income countries . From the available literature the data would suggest that most children , who are without associated risk factors ( such as prematurity , haemolysis , sepsis , hypoxic ischaemic encephalopathy and weight loss ) and do not present with acute bilirubin encephalopathy and who receive appropriate timely assessment and treatment , will not have serious adverse neurodevelopmental sequelae .
CASE STUDIES
Case study one
JAMES , four days old , is brought to the
GP by his concerned mum . James is jaundiced and Mum is also concerned he is sleepy and not feeding very well . He has been jaundiced for two days . James is exclusively breastfed
urement device would be univer-
but is falling asleep after 5-10 minutes .
sally accessible , accurate , easy to
Mum feels like her milk supply is now
use and inexpensive . Various tech-
good , having ‘ come in ’ the previous
nologies are emerging to meet this
day . James has only had two wet nap-
need and overcome the limitations
pies in the last 24 hours and his stool is
of existing clinical tools . In recent
still predominantly meconium .
years , various novel hyperbiliru-
There were no concerns during
binaemia detection technologies
pregnancy ( James is her first ) with
have been developed which , in
normal scans and a reassuring panel
combination with automated bilirubin nomogram plotting systems such as the BiliApp app ( based on NICE guidelines , and only available in the US ), may enable caregivers to more efficiently manage neonatal jaundice . 46 The majority of these studies utilise smartphone camera technology , optical processing with or without colour calibration cards , and various mathematical algorithms to estimate SBR through imaging of jaundiced newborn skin or icteral sclerae . With great potential to significantly improve
Figure 6 . Types of choledochal cysts .
Type I : Dilatation of extrahepatic biliary duct ; Type II : Cyst from common bile duct ( CBD ); Type III : Choledochocele or dilatation of distal part of CBD ; Type IV : dilatation of both extrahepatic and intrahepatic duct ; Type V : Caroli disease , dilatation of intrahepatic duct only .
of infective serology . Maternal blood group is B positive , and there are no antibodies .
James was born by normal vaginal delivery after spontaneous labour at 40 weeks and two days . His birthweight was 3.15kg and his Apgar score was nine at one and five minutes . He had one TCB in hospital before discharge on day two , which was below the phototherapy treatment threshold . A newborn screening test was sent .
The family originates from Malaysia . James ’ dad was jaundiced as a neonate but they are not sure if treat-
morbidity and mortality rates , par-
ment was required . On examination ,
ticularly in low- and middle-income
a water-soluble form ( lumirubin )
secondary to immune-mediated
exchange transfusion is to remove
James is quiet but wakes and behaves
settings , or indeed in geograph-
that is excreted in bile , and to a
haemolysis , IV immunoglobulin
bilirubin , antibodies and the prod-
normally when handled , with nor-
ically remote areas around the world , smartphone neonatal bilirubin assessment holds great prom-
lesser extent , in urine without the need for conjugation . 82-84 The efficacy of phototherapy depends on
may obviate the need for the most aggressive therapy , double blood-
85 , 86 volume exchange transfusion .
ucts of haemolysis while preserving as close to constant a circulating blood volume and maintenance
mal tone and reflexes . He is jaundiced throughout the face , sclera , upper body and down to his torso . He weighs
ise to reduce the impacts of severe neonatal jaundice .
TREATMENT
Phototherapy
THE treatment of neonatal jaun-
the wavelength of light ( ideally 450-460nm ), luminance of the light source and the relative degree of newborn skin exposure . 84
Other routine management includes the optimisation of the
Exchange transfusion
Double blood-volume exchange
transfusion with packed red blood cells and fresh frozen plasma is used for the management of
of haemodynamic and acid-base homeostasis .
Neonatal exchange transfusion is a complex , resource-intensive , time-consuming and potentially high-risk procedure . The risks
2.72kg , has a heart rate of 124bpm , respiratory rate of 42 breaths per minute , temperature of 36.8 ° C , and an oxygen saturation ( measured in the lower limb ) of 97 %. His anterior fontanelle is slightly sunken . Heart sounds are
dice is routine in newborn care
baby ’ s hydration status with feed-
severe hyperbilirubinaemia and / or
associated with an exchange trans-
normal with no added sound , he
health facilities . The primary mode
ing support , and recognition and
haemolysis when other treatment
fusion include thrombocytopenia ,
has a normal breathing pattern and
and mainstay of treatment is pho-
treatment of underlying conditions
methods such as phototherapy have
hypocalcaemia , hypoglycaemia
chest auscultation . Morphology and
totherapy ( see figures 8 and 9 ), which works by photoisomerisation of unconjugated bilirubin to
such as possible sepsis . In cases of extremely high or rapidly rising levels of SBR suspected to be
been inadequately effective or when SBR levels are in the potentially neurotoxic range . 87 , 88 The aim of
and central line malfunction . 89-91 It must therefore be carefully balanced with the anticipated
abdominal examination are normal . Identified risk factors for neonatal hyperbilirubinaemia include male