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