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Metabolic:
Inborn errors of metabolism
CF
Alpha-1-antitrypsin deficiency
WHAT IS YOUR DDX OF UNCONJUGATED (INDIRECT) HYPERBILI OF THE
NEONATE?
Benign:
Physiologic
Breast milk jaundice
Hemolysis:
ABO incompatibility
Physiologic breakdown of birth trauma hematomas
IVH
Spherocytosis
G6PD
Pyruvte kinase deficiency
Sickle cell
Infection:
TORCH
Sepsis (esp UTI)
Obstructive:
Meconium ileus
Hirschsrungs
Duodenal atresia
Pyloric stenosis
Metabolic/genetic:
Galactosemia
Congenital hypothyroidism
Crigler-Najjar syndrome (absence or deficient UDPGT)
Gilberts
WHY CAN BREASTFEEDING LEAD TO JAUNDICE?
Caloric derivation and dehydration from delayed milk production (takes 2-5 days before
maternal milk production up to normal) leading to increased enterohepatic circulation
Inhibition of hepatic B-UGT
WHAT PRESENTATIONS OF NEONATAL JAUNDICE REQUIRE A WORKUP?
Onset in the 1st 24 hr of life
Unwell appearing neonate (lethargy, irritability, poor feeding, temperature instability, vomiting)
> 20% TSB is conjugated
Onset after 7-10 d of life
Associated anemia
Persists after 3 weeks (exclude exclusively breast fed neonates without any of above and who
appear well)
WHAT ARE 3 TREATMENT MODALITIES USED TO TREAT POTENTIALLY
HARMFUL LEVELS OF HYPERBILIRUBINEMIA IN THE NEONATE?
Phototherapy:
Decreases bili level 15-25%
Blue light converts unconjugated bili to a water soluble compound that is excreted in urine and
stool
Ivig:
Used with fetal maternal ABO or Rh incompatibility
Exchange Transfusion:
Decreases bili level by ~ 50%
Indicated if: signs of intermediate to severe acute bilirubin encephalopathy, level as per AAP
guidelines, rising level despite phototherapy
REFERENCES
AAP Guidelines :Management of hyperbilirubinemia in the Newborn Infant 35 or more Weeks of
Gestation. Pediatrics. 2004;114(1): 297-316
Watchko, JF. Hyperbilirubinemia and Bilirubin toxicitiy in the Late Preterm Infant. Clin Perinat.
2006;33:839-852
Colletti, JE, et al. An Emergency Medicine Approach to Neonatal Hyperbilirubinemia. Emerg
Med Clin N AM. 2007;25:1117-1135