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 /
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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
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SBR correlation rules such as meas- |
require feeding support via engage- |
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urement of a serum sample when |
ment of allied healthcare profession- |
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the TCB is within 50μmol / L ( about |
als such as lactation consultants and |
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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 . |
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these can substantially reduce the need for neonatal blood sampling while safely managing the risk of |
GP management
The GP management of neonatal
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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
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of the change in dermal bilirubin |
wide variations in the categorisation |
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during treatment . Most guidelines advise against TCB measurement |
Figure 5 . Biliary atresia . |
and definitions of neonatal hyperbilirubinaemia and associated long- |
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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-
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CHD = common hepatic duct , LHD = left hepatic duct and RHD = right hepatic duct .
Drriad / CC BY-SA 3.0 / bit . ly / 3Fm49Ja
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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
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urement device would be univer- |
but is falling asleep after 5-10 minutes . |
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sally accessible , accurate , easy to |
Mum feels like her milk supply is now |
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use and inexpensive . Various tech- |
good , having ‘ come in ’ the previous |
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nologies are emerging to meet this |
day . James has only had two wet nap- |
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need and overcome the limitations |
pies in the last 24 hours and his stool is |
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of existing clinical tools . In recent |
still predominantly meconium . |
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years , various novel hyperbiliru- |
There were no concerns during |
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binaemia detection technologies |
pregnancy ( James is her first ) with |
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have been developed which , in |
normal scans and a reassuring panel |
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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-
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morbidity and mortality rates , par- |
ment was required . On examination , |
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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 |
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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- |
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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 .
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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 |
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ise to reduce the impacts of severe neonatal jaundice . |
TREATMENT
Phototherapy
THE treatment of neonatal jaun-
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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
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Exchange transfusion
Double blood-volume exchange
transfusion with packed red blood cells and fresh frozen plasma is used for the management of
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of haemodynamic and acid-base homeostasis .
Neonatal exchange transfusion is a complex , resource-intensive , time-consuming and potentially high-risk procedure . The risks
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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 |
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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 |
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health facilities . The primary mode |
ing support , and recognition and |
haemolysis when other treatment |
fusion include thrombocytopenia , |
has a normal breathing pattern and |
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and mainstay of treatment is pho- |
treatment of underlying conditions |
methods such as phototherapy have |
hypocalcaemia , hypoglycaemia |
chest auscultation . Morphology and |
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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 |