Download the new app today ausdoc ausdoc . com com . au au
HOW TO TREAT 33
CF
Download the new app today ausdoc ausdoc . com com . au au
13 DECEM- NOVEM- BER X MONTH 2022 library at www . ausdoc . com . au / therapy-update
LEARN MORE ONLINE Visit our Therapy Update
HOW TO TREAT 33
( see standard charts ) and the conjugated should be less than 10 %.
The SBR is plotted on the local phototherapy treatment threshold guideline .
The differential diagnoses include a variety of anatomic , infectious , autoimmune , genetic , metabolic and congenital conditions . Pathological causes for conjugated hyperbilirubinaemia include bacterial sepsis , galactosaemia , tyrosinaemia , panhypopituitarism , bile acid synthetic defects and other inborn errors of metabolism .
Early discussion with a gastroenterologist is vital as the timing of the diagnosis of biliary atresia is an important prognostic factor . Where local services are not available , referral to a tertiary paediatric critical care centre able to investigate and , in particular , to exclude biliary atresia is essential .
CONCLUSION
NEONATAL jaundice is a common issue in the first few weeks of life . It is important that timed jaundice levels are checked objectively and interpreted in the context of each individual ’ s risk factors . In the advent of earlier hospital discharge and home-birthing , GPs need to be equipped to assess , manage and appropriately refer cases of neonatal jaundice .
RESOURCES
• NSW Health : Jaundice identification and management in neonates ≥ 32 weeks gestation bit . ly / 3IYsDJF
• NSW Health : Critical care tertiary referral networks ( paediatrics ) bit . ly / 42poWoj
• Safer Care Victoria : Jaundice in neonates bit . ly / 3B6Qd37
• The Royal Women ’ s Hospital ( Melbourne ): Jaundice ( hyperbilirubinaemia ) in newborn babies ≥ 35 weeks gestation bit . ly / 3y3Anox
• The Royal Children ’ s Hospital Melbourne — Clinical practice guidelines : Jaundice in early infancy bit . ly / 2I4Ryy6
• Queensland Health — Queensland clinical guidelines : Neonatal jaundice bit . ly / 3mgzJBc
• SA perinatal practice guideline : Neonatal jaundice bit . ly / 3maJSj0
• Government of WA Child and Adolescent Health Service and Perth Children ’ s Hospital — ED guidelines : Neonatal jaundice bit . ly / 41LZx8X
• Information for parents : — NHS : Newborn jaundice bit . ly / 3Y4Gkfj
— Harvard Health Publishing : New guidelines on newborn jaundice — What parents need to know bit . ly / 3EMv5S9
— Raising Children Network : Jaundice in newborns bit . ly / 41AC3DC
— The Sydney Children ’ s Hospitals Network : Jaundice in newborn babies bit . ly / 3KLZ1Se
References Available on request from howtotreat @ adg . com . au
If any of the following :
• Unwell baby ( eg , febrile , lethargic , pale , abnormal vital signs )
• Jaundice less than 48 hours
• Dark urine and pale stools
Urgent referral to local acute paediatric services
Figure 10 . Management flow chart .
How to Treat Quiz .
GO ONLINE TO COMPLETE THE QUIZ ausdoc . com . au / how-to-treat
1 . Which THREE statements regarding neonatal jaundice are correct ? a It is due to variable degrees of conjugated bilirubin deposition . b It is clinically recognisable as yellowing or icterus of the newborn ’ s skin and sclerae . c The condition is clinically apparent in 50-80 % of newborns . d It has multifactorial aetiology in most cases .
2 . Which TWO are features of the first phase of bilirubin encephalopathy ? a Lethargy . b A high-pitched cry . c Poor feeding . d Irritability .
3 . Which THREE are major pathophysiological causes or associations with severe hyperbilirubinaemia ? a ABO and other blood group incompatibility . b G6PD deficiency . c Maternal age over 40 . d Infection .
Jaundiced baby presents to GP
4 . Which TWO statements regarding neonatal jaundice are correct ? a Unconjugated bilirubin is water-soluble and can thus be excreted via urine and faeces . b Phototherapy is usually the primary treatment required for unconjugated neonatal jaundice . c Idiopathic or physiological jaundice is typically present for around 10 days before subsiding . d Prolonged unconjugated jaundice is more common in breastfed term neonates beyond 14 days of age .
5 . Which THREE may be causes of conjugated hyperbilirubinaemia in a neonate ? a Biliary atresia . b Breastfeeding . c Hepatitis . d Extrahepatic obstruction .
GP clinical assessment :
NEONATAL JAUNDICE
6 . Which ONE is NOT a consistent risk factor for severe unconjugated hyperbilirubinaemia ? a Blood group incompatibility . b Weight loss . c Advanced maternal age . d Lower gestational age .
7 . Which aspects are covered in the clinical assessment of a baby with jaundice ? a Assessment of hydration . b Red flags . c A detailed history . d Level of alertness and responsiveness to handling , tone and reflexes .
8 . Which ONE is the gold standard method for quantification of hyperbilirubinaemia ? a Measurement of conjugated bilirubin in the blood . b Serial visual inspections .
EARN CPD OR PDP POINTS
Well baby , jaundice for more than 48 hours :
History focused on risk factors :
• Family history of neonatal jaundice
• Maternal blood group and antenatal antibodies
• Delivery mode ( risk of bruising )
• Feeding and growth ( breast / formula , weight gain / loss since birth )
• Maternal antenatal infection serology , delivery mode , feeding and growth , urine and stool outputs
• Urine and stool outputs — check for signs of cholestasis
Examination :
General systems examination
• Activity , tone , posture
• Hydration status
• Bruising / cephalohaematoma
• Hepatosplenomegaly
• Degree and distribution of jaundice
Investigations for babies younger than two weeks and jaundiced for longer than 48 hours :
• Arrange total SBR with conjugated fraction and plot total level on local state nomogram for treatment thresholds
• Consider FBC , film , blood group , DAT , G6PD assay
Investigations for babies jaundiced for longer than two weeks :
• Arrange total SBR with conjugated fraction and plot total level on local state nomogram for treatment thresholds
• Thyroid function tests , FBC , film , blood group , DAT , G6PD assay
• LFTs if conjugated greater than 17 µ mol / L
GP management :
• SBR on , near or above phototherapy threshold : → urgent referral to local acute paediatric services for treatment
• Conjugated bilirubin greater than 17 µ mol / L or abnormal thyroid function tests : → urgent referral to local acute paediatric services for treatment
• Manage any comorbidities such as feeding issues and follow-up investigations
• SBR below but within 50 µ mol / L of the phototherapy , plan ongoing monitoring with local paediatric services
• SBR greater than 50 µ mol / L below phototherapy , plan ongoing monitoring dependent on rate of rise of SBR ( if known ) and risk factors . Educate caregivers :
• How to recognise more severe jaundice
• How to get advice if jaundice is more severe or they are concerned for any other reason
• If jaundice persists for longer than 14 days
• Naphthalene risks
• Read this article and take the quiz via ausdoc . com . au / how-to-treat
• Each article has been allocated one hour by the RACGP and ACRRM .
• RACGP points are uploaded every six weeks and ACRRM points quarterly .
c Direct measurement of bilirubin in blood . d Measurement of bilirubin in urine .
9 . Which TWO statements regarding the investigations of a baby with jaundice are correct ? a Visual inspection is useful to exclude jaundice . b TCB is a non‐invasive , painless point-of-care method of estimating SBR . c TCB is invaluable in the monitoring of a baby ’ s response to phototherapy . d The forehead should routinely be used for the measurement of TCB .
10 . Which THREE modalities may be appropriate in the management of a baby with jaundice ? a Phototherapy . b Whole blood transfusion . c Double volume exchange transfusion with packed red blood cells and fresh frozen plasma . d Treatment of underlying aetiologies , comorbidities or risks .