prematurity, neonatology, sids jay green emergency medicine resident, pgy-2 july 19, 2007

Prematurity, Prematurity, Neonatology, SIDSNeonatology, SIDS

Jay GreenJay GreenEmergency Medicine Resident, PGY-Emergency Medicine Resident, PGY-

22July 19, 2007July 19, 2007

OutlineOutline

Apparent Life-Threatening EventsApparent Life-Threatening Events Sudden Infant Death SyndromeSudden Infant Death Syndrome Other causes of apneaOther causes of apnea ±±Quick snappersQuick snappers

Won’t coverWon’t cover– Fever/sepsis in the newbornFever/sepsis in the newborn– Bronchopulmonary dysplasiaBronchopulmonary dysplasia– Cerebral palsyCerebral palsy– Obstructive hydrocehpalusObstructive hydrocehpalus

Case 1Case 1

5mo M, stopped breathing x ?1-2min5mo M, stopped breathing x ?1-2min Blue colour, limpBlue colour, limp Resolved before EMS arrivedResolved before EMS arrived No vomiting, no sz activityNo vomiting, no sz activity Position - supinePosition - supine Noise - ?chokingNoise - ?choking No abnormal eye mvtsNo abnormal eye mvts No intervention by parentsNo intervention by parents

Case 1 contCase 1 cont

OB Hx: no complications, SVD @ OB Hx: no complications, SVD @ 38wks38wks

PMH: well childPMH: well child FHxFHx

– øøApnea, Apnea, øøSIDS, SIDS, øøSz, Sz, øøCHDCHD

Case 1 contCase 1 cont

O/E:O/E:– Well-looking childWell-looking child– VitalsVitals

HR 125, bp 85/55, RR 35, T 36HR 125, bp 85/55, RR 35, T 3699

– Nothing remarkable to findNothing remarkable to find

Anything specific not to miss O/E?Anything specific not to miss O/E?– Fundoscopy, SFundoscopy, SppOO22

What is on your differential What is on your differential diagnosis?diagnosis?

Apparent Life-Threatening Apparent Life-Threatening EventEvent

ALTEALTE

ALTE DefinitionALTE Definition

An episode that is An episode that is frightening to the frightening to the observerobserver and is characterized by and is characterized by some combination of:some combination of:– ApneaApnea– Colour changeColour change– Marked change in muscle toneMarked change in muscle tone– ChokingChoking– GaggingGagging

National Institutes of Health Consensus Development National Institutes of Health Consensus Development Conference on Infantile Apnea and Home MonitoringConference on Infantile Apnea and Home Monitoring

ALTE Quick StatsALTE Quick Stats

Incidence 0.5-6%Incidence 0.5-6% 4-8% of SIDS had a previous ALTE4-8% of SIDS had a previous ALTE

– Not considered same disease processNot considered same disease process 82% occur between 8am-8pm82% occur between 8am-8pm Usually < 6mo, avg 8-14wksUsually < 6mo, avg 8-14wks Can be > 1yrCan be > 1yr 13% risk of death if needed CPR and 13% risk of death if needed CPR and

discovered during sleepdiscovered during sleep

ALTE Hx/ExamALTE Hx/Exam

Most NB parts of ED diagnostic Most NB parts of ED diagnostic evaluationevaluation

HistoryHistory– Colour, tone, resp effortColour, tone, resp effort– Onset (sleep, feeding, awake), durationOnset (sleep, feeding, awake), duration– Position (prone, sitting, supine)Position (prone, sitting, supine)– Noises (stridor, choking)Noises (stridor, choking)– Eye movementsEye movements– VomitingVomiting– InterventionIntervention

ALTE - ExamALTE - Exam

PE usually normalPE usually normal

N = 73N = 73 Dilated fundoscopic examDilated fundoscopic exam

– Retinal hemorrhages in 1pt, child abuse Retinal hemorrhages in 1pt, child abuse in 4in 4

Back to Case 1Back to Case 1

5mo M ?ALTE5mo M ?ALTE

What would you like to do now?What would you like to do now?– Labs?Labs?– Imaging?Imaging?– Discharge patient?Discharge patient?

ALTE InvestigationsALTE Investigations

50% have specific diagnosis found50% have specific diagnosis found– Infection, GI, SzInfection, GI, Sz

ALTE InvestigationsALTE Investigations

196 infants with ALTE, mean age 2mo196 infants with ALTE, mean age 2mo 83% hospital admission83% hospital admission 50% had normal exam50% had normal exam 25% had infection/fever25% had infection/fever Diagnoses:Diagnoses:

– Seizure (25%), GER (18%), febrile convulsion Seizure (25%), GER (18%), febrile convulsion (12%), LRTI (9%), apnea (9%)(12%), LRTI (9%), apnea (9%)

No infant subsequently diedNo infant subsequently died

65 infants with ALTE, mean age 7wks65 infants with ALTE, mean age 7wks 100% hospital admission (required)100% hospital admission (required) 54% had normal exam54% had normal exam Diagnoses:Diagnoses:

– GER (25%), unknown (23%), pertussis GER (25%), unknown (23%), pertussis (9%), Other LRTI (9%), Sz (9%), UTI (8%)(9%), Other LRTI (9%), Sz (9%), UTI (8%)

No infant subsequently diedNo infant subsequently died

Thanks Yael!

Investigation protocolInvestigation protocol– 13% anemia, 33% 13% anemia, 33% ↑WBC (50% had inf)↑WBC (50% had inf)– Metabolic screen, urine reducing substances, Metabolic screen, urine reducing substances,

ammonia not helpfulammonia not helpful– ↓↓Bicarb in 20% - 7 dx with sepsis/szBicarb in 20% - 7 dx with sepsis/sz– ↑↑Lactate in 7, 5 had serious illnessLactate in 7, 5 had serious illness– U/A, pertussis swab useful in 5% & 8%U/A, pertussis swab useful in 5% & 8%– CXR abN in 9 who had N examCXR abN in 9 who had N exam

Return to Case 1Return to Case 1

Labs NLabs N CXR NCXR N ECG NECG N Nasal swab, urine cultures pendingNasal swab, urine cultures pending

What would you like to do now?What would you like to do now?

ALTE - Some PerspectiveALTE - Some Perspective

Pre-hospital study, retrospectivePre-hospital study, retrospective N = 60, mean age 3.1moN = 60, mean age 3.1mo 83% no distress, 13% mild distress, 3% 83% no distress, 13% mild distress, 3%

moderate distressmoderate distress DiagnosesDiagnoses

– Pneumonia (12%), sz (8%), sepsis (7%), ICH Pneumonia (12%), sz (8%), sepsis (7%), ICH (3%), bacterial meningitis (2%), anemia (3%), bacterial meningitis (2%), anemia (2%)(2%)

ALTE can be presenting sign of serious ALTE can be presenting sign of serious illness, even in well-looking childillness, even in well-looking child Thanks Yael!

ALTE DispositionALTE Disposition

Most studies recommend mandatory Most studies recommend mandatory period of inpatient observationperiod of inpatient observation

Majority suffer only 1 eventMajority suffer only 1 event No single test has a high PPV for No single test has a high PPV for

detecting anything that will alter the detecting anything that will alter the outcomeoutcome

Recurrence rate for severe ALTE as high Recurrence rate for severe ALTE as high as 68% in one studyas 68% in one study– More likely in the few days after first eventMore likely in the few days after first event

ALTE DispositionALTE Disposition

If no cause for ALTE foundIf no cause for ALTE found– Referred to as “apnea of infancy”Referred to as “apnea of infancy”– ±±home apnea-bradycardia monitoringhome apnea-bradycardia monitoring

Lack efficacy, frequent false alarms, Lack efficacy, frequent false alarms, misinterpretation of alarm by parentsmisinterpretation of alarm by parents

Potential candidatesPotential candidates– Premature infants exhibiting apnea beyond termPremature infants exhibiting apnea beyond term– Term infants with ALTE requiring resusTerm infants with ALTE requiring resus– Siblings of 2+ SIDS victimsSiblings of 2+ SIDS victims– Infants with BPD/tracheostomiesInfants with BPD/tracheostomies

ALTE CausesALTE Causes

InfectionInfection SeizureSeizure A/W ObstructionA/W Obstruction Breath-Holding SpellsBreath-Holding Spells GERGER MetabolicMetabolic NonaccidentalNonaccidental

See EM See EM Reports Aug Reports Aug 7, 20067, 2006

ALTE ALTE SIDS? SIDS?

Prospective cohort study, N=141, 8yrsProspective cohort study, N=141, 8yrs ?Association between SIDS & ALTE?Association between SIDS & ALTE ConclusionsConclusions

– RF for all ALTE’sRF for all ALTE’s Common to SIDS: single parent, FHx infant death, Common to SIDS: single parent, FHx infant death,

smoking during preg, marked night sweatingsmoking during preg, marked night sweating Early behaviours: repeated apnea, cyanotic episodes, Early behaviours: repeated apnea, cyanotic episodes,

feeding difficulties, marked pallorfeeding difficulties, marked pallor

– RF for “idiopathic ALTE”RF for “idiopathic ALTE” No common SIDS RFNo common SIDS RF

– No subsequent SIDS deathsNo subsequent SIDS deaths

ConclusionsConclusions– ALTE/SIDS not part of the same disease ALTE/SIDS not part of the same disease

processprocess– SIDS prevention programs not expected SIDS prevention programs not expected

to lower ALTE frequencyto lower ALTE frequency

ALTE Take-home PointsALTE Take-home Points

Scary + apnea, Scary + apnea, ∆∆colour, choking, colour, choking, ∆tone∆tone

Usually < 6moUsually < 6mo Well-looking ALTE Well-looking ALTE ?serious illness ?serious illness Inpatient work-upInpatient work-up Not same disease process as SIDSNot same disease process as SIDS

Questions?Questions?

Case 2Case 2

4mo F, found blue, not breathing in 4mo F, found blue, not breathing in cribcrib

EMS called, begin CPR, and patch inEMS called, begin CPR, and patch in– Baby cyanotic, initial rhythm asystole, Baby cyanotic, initial rhythm asystole,

no resp effortsno resp efforts What do you tell them?What do you tell them?

– Continue CPR and come in?Continue CPR and come in?– Call it in the field?Call it in the field?

Sudden Infant Death Sudden Infant Death SyndromeSyndrome

Sudden death of an infant <1y oldSudden death of an infant <1y old Remains unexplained after Remains unexplained after

investigation:investigation:– Complete autopsyComplete autopsy– Examination of the death sceneExamination of the death scene– A review of the clinical historyA review of the clinical history

National Institute of Child Health and Human DevelopmentNational Institute of Child Health and Human Development

SIDS Fast FactsSIDS Fast Facts

US dataUS data– 0.72/1000 live births in 19980.72/1000 live births in 1998– Declining incidenceDeclining incidence– 3000 deaths/yr3000 deaths/yr

95% < 6-8mo, peak 2-4mo95% < 6-8mo, peak 2-4mo 1% < 1mo, 2% > 2yr1% < 1mo, 2% > 2yr

What are some risk factors for SIDS?What are some risk factors for SIDS? MaternalMaternal

– SmokingSmoking– Drug useDrug use– ↓↓SESSES– Age<20 at G1Age<20 at G1– EthnicityEthnicity– ↓↓EducationEducation– No prenatal careNo prenatal care

PrenatalPrenatal– IUGRIUGR– MultiplesMultiples– PrematuriyPrematuriy– BW < 2500gBW < 2500g

PostnatalPostnatal– Prone sleepingProne sleeping– ETSETS– Warm tempWarm temp– Loose beddingLoose bedding– Soft surfaceSoft surface– Bed sharingBed sharing– ?infection?infection– ?GER?GER– ?arrhythmia?arrhythmia

What is the most important modifiable risk factor?Prone sleeping 78%17%, SIDS ↓ 40%!

SIDS – What Happens?SIDS – What Happens?

>70 theories: “triple-risk theory” – Rosen’s>70 theories: “triple-risk theory” – Rosen’s

Immature cardiorespiratory control

Autonomic dysfunction

Predisposing factors

↓ baroreceptor reflex

↓vasomotor control

↓central venous return, CO, bp

Sleep

Exacerbate these effects

Progressive bradycardia

Poor lung perfusion hypoxia

Prone sleep

URTI

Overheating

SIDS

Physiologic stuff

Is sleep ever bad…I guess so…

Various badness that doesn’t helpSIDS

Case 2 contCase 2 cont

4mo F just arrived in your ED4mo F just arrived in your ED CPR continuingCPR continuing Pupils fixed mid-dilatedPupils fixed mid-dilated Rhythm asystoleRhythm asystole Unknown downtimeUnknown downtime

How long do you continue the resus?How long do you continue the resus?– ~3 rounds of drugs~3 rounds of drugs

SIDS OutcomeSIDS Outcome

After infant declared deadAfter infant declared dead– Blood, urine, skin samplesBlood, urine, skin samples– Family meetingFamily meeting– Coroner notifiedCoroner notified

House inspectionHouse inspection AutopsyAutopsy

SIDS Pathologically SIDS Pathologically SpeakingSpeaking

Nothing pathognomonicNothing pathognomonic Some typical findingsSome typical findings

– PA smooth muscle hypertrophyPA smooth muscle hypertrophy– RVHRVH– ↑ ↑ hepatic hematopoiesishepatic hematopoiesis– ↑ ↑ periadrenal brown fatperiadrenal brown fat– Adrenal medullary hyperplasiaAdrenal medullary hyperplasia– Carotid body abnormalitiesCarotid body abnormalities– Brainstem gliosisBrainstem gliosis

SIDS EffectsSIDS Effects

Guilt, blaming, social alienationGuilt, blaming, social alienation ↑ ↑ miscarriage rate, divorce, infertilitymiscarriage rate, divorce, infertility Potentially helpful steps:Potentially helpful steps:

– Openly accepting grief reactionsOpenly accepting grief reactions– Allowing family to vocalize their feelingsAllowing family to vocalize their feelings– Clarifying misconceptionsClarifying misconceptions– Allowing the family to hold/be along with infantAllowing the family to hold/be along with infant– Private place for family to gatherPrivate place for family to gather– Explanation of cause of deathExplanation of cause of death

Case 2 contCase 2 cont

Unsuccessful resuscitationUnsuccessful resuscitation Infant declared deadInfant declared dead Parents inform you that infant has a Parents inform you that infant has a

twin brothertwin brother

What should you do about this?What should you do about this?– Inform them there’s no increased risk?Inform them there’s no increased risk?– Admit the twin for observation?Admit the twin for observation?

SIDS - TwinsSIDS - Twins

Cohort studies looking at twinsCohort studies looking at twins– Variable findings, 2x increased risk of Variable findings, 2x increased risk of

SIDSSIDS Any sibling of SIDS victimsAny sibling of SIDS victims

– 5-6x increased risk of SIDS5-6x increased risk of SIDS

Reasonable to admit the twin for a Reasonable to admit the twin for a period of observationperiod of observation

SIDS PreventionSIDS Prevention

Non-prone sleeping (supine Non-prone sleeping (supine preferred)preferred)

No sleeping in waterbeds, sofas, soft No sleeping in waterbeds, sofas, soft mattresses/surfacesmattresses/surfaces

No soft materials in sleeping env’tNo soft materials in sleeping env’t Avoid bed-sharing and co-sleepingAvoid bed-sharing and co-sleeping Avoid overheatingAvoid overheating

Retrospective review, 10yrsRetrospective review, 10yrs All deaths < 1yr in QuebecAll deaths < 1yr in Quebec 396 SIDS deaths396 SIDS deaths Infants <1moInfants <1mo

– 10.2% died sitting10.2% died sitting Infants >1moInfants >1mo

– 1.4% died sitting1.4% died sitting– P<0.001P<0.001– RR 7.35RR 7.35

??↑ risk with ↑ time↑ risk with ↑ time ?↑ risk with position?↑ risk with position No ↑ risk with No ↑ risk with

premature infantspremature infants

Conclusions:-an excess of infants <1mo diedin sitting position compared tothose >1mo-length of time in seat andposition may be NB contributors

SIDS Take-home pointsSIDS Take-home points

Peak age 2-4moPeak age 2-4mo Prone sleeping most NB modifiable RFProne sleeping most NB modifiable RF SIDS death can be called in the fieldSIDS death can be called in the field Resus of asystolic neonate x ~3 roundsResus of asystolic neonate x ~3 rounds Admit twin of SIDS victimAdmit twin of SIDS victim

Questions?Questions?

Apnea DefinitionsApnea Definitions

Pathological apneaPathological apnea– Respiratory pause > 20sec or assoc with Respiratory pause > 20sec or assoc with

cyanosis, pallor, hypotonia, bradycardiacyanosis, pallor, hypotonia, bradycardia Apnea of prematurityApnea of prematurity

– Periodic breathing with pathological apneaPeriodic breathing with pathological apnea Apnea of infancyApnea of infancy

– Infant > 37wks, pathological apnea or shorter Infant > 37wks, pathological apnea or shorter apneic pauses & bradycardia, cyanosis, pallor, apneic pauses & bradycardia, cyanosis, pallor, or hypotoniaor hypotonia

– ““Idiopathic ALTE”Idiopathic ALTE”

Case 3Case 3

10d F breathing pauses lasting ~5s10d F breathing pauses lasting ~5s 4-5 episodes/min, comes & goes4-5 episodes/min, comes & goes Born at 39wksBorn at 39wks Uncomplicated preg/delivery to GUncomplicated preg/delivery to G11PP11

No fever, rash, lethargyNo fever, rash, lethargy Feeding wellFeeding well 10-12 wet diapers/d, 3-4 seedy 10-12 wet diapers/d, 3-4 seedy

stools/dstools/d Regained birthweight at 7dRegained birthweight at 7d

Case 3Case 3

O/EO/E– VS NVS N– Well looking child, no apneic episodes in Well looking child, no apneic episodes in

EDED

What next?What next?– Labs?Labs?– Imaging?Imaging?– Discharge?Discharge?– What do you think is going on?What do you think is going on?

Periodic BreathingPeriodic Breathing

NormalNormal 3 or more pauses of >3sec with less 3 or more pauses of >3sec with less

than 20sec of N respirations between than 20sec of N respirations between pausespauses

Treatment?Treatment?– CaffeineCaffeine

MethylxanthinesMethylxanthines

Helpful in apnea of prematurity and Helpful in apnea of prematurity and in reducing periodic breathingin reducing periodic breathing

Caffeine better than theophyllineCaffeine better than theophylline– Longer half-lifeLonger half-life– Wider therapeutic indexWider therapeutic index– More reliable absorptionMore reliable absorption

Caffeine citrate 20mg/kg IV/PO loadCaffeine citrate 20mg/kg IV/PO load– 5-8mg/kg OD5-8mg/kg OD

Why do we use caffeine?Why do we use caffeine?

Caffeine – Mechanism of Caffeine – Mechanism of ActionAction

Increases levels of 3’5’-cyclic AMP by Increases levels of 3’5’-cyclic AMP by inhibiting phosphodiesteraseinhibiting phosphodiesterase

CNS stimulant CNS stimulant – Increases medullary resp center sensitivity to Increases medullary resp center sensitivity to

COCO22

Stimulates central inspiratory driveStimulates central inspiratory drive Improves skeletal muscle contraction Improves skeletal muscle contraction

– Diaphragmatic contractilityDiaphragmatic contractility Prevention of apnea may occur by Prevention of apnea may occur by

competitive inhibition of adenosine competitive inhibition of adenosine

CaffeineCaffeine

N=15 with periodic breathing (PB) Conclusions

– Weak correlation btw GER and PB– Theophylline/caffeine

Marked reduction of PB Increases GER

Skopnik H et al. Effect of methylxanthines on periodic respiration and acid gastro-esophageal reflux in newborn infants. Monatsschrift Kinderheilkunde 1990;138(3):123-7

Case 4Case 4 4d M apneic episodes today lasting ~30s4d M apneic episodes today lasting ~30s

– ?A bit blue during episodes?A bit blue during episodes Discharged from hospital todayDischarged from hospital today Infant born @ 36Infant born @ 3611 wks wks Uncomplicated preg/deliveryUncomplicated preg/delivery O/EO/E

– VS N, well child, no apneic episodes in EDVS N, well child, no apneic episodes in ED Investigations?Investigations? Disposition?Disposition? What does this child have?What does this child have?

Apnea of PrematurityApnea of Prematurity

Periodic breathing with apneic Periodic breathing with apneic episodes > 20secepisodes > 20sec

Usually resolves by 37wks gestationUsually resolves by 37wks gestation Management?Management?

– Inpatient work-up/monitoringInpatient work-up/monitoring – Caffeine citrate 20mg/kg IV/PO loadCaffeine citrate 20mg/kg IV/PO load

5-8mg/kg OD5-8mg/kg OD

Apnea Take-home PointsApnea Take-home Points

Periodic breathing is normalPeriodic breathing is normal– 3+ pauses >3sec with <20sec of N resps 3+ pauses >3sec with <20sec of N resps

btwbtw Caffeine helps in periodic breathing and Caffeine helps in periodic breathing and

apnea of prematurityapnea of prematurity Pathological apnea is >20secPathological apnea is >20sec Pathological apnea always deserves Pathological apnea always deserves

W/UW/U

Questions?Questions?

Quick Snapper #1Quick Snapper #1 5d M poor feeding & vomiting x 1d5d M poor feeding & vomiting x 1d D/C yesterdayD/C yesterday Born 36Born 3611, difficult labour, decels, forceps, difficult labour, decels, forceps Breast-fed, with bottle supplementationBreast-fed, with bottle supplementation Gaining weight x 2dGaining weight x 2d No bloody stools, non-bilious emesis, no No bloody stools, non-bilious emesis, no

feverfever O/EO/E

– Vitals NVitals N– Abdo ?distendedAbdo ?distended

Investigations?Investigations?

Quick Snapper #1Quick Snapper #1

Necrotizing Enterocolitis Necrotizing Enterocolitis (NEC)(NEC)

Mucosal/transmural intestinal Mucosal/transmural intestinal necrosisnecrosis

Most common GI emergency, but Most common GI emergency, but often presents prior to d/coften presents prior to d/c

90% premature90% premature >32wks usually present in 1>32wks usually present in 1stst week week

of lifeof life– Can be >3mo in VLBW infantsCan be >3mo in VLBW infants

NEC PathogenesisNEC Pathogenesis

UnknownUnknown Probably combination ofProbably combination of

– Mucosal injury (ischemia, infection, Mucosal injury (ischemia, infection, inflammation)inflammation)

– Host's response to injury (circulatory, Host's response to injury (circulatory, immunologic, inflammatory)immunologic, inflammatory)

RFRF– Aggressive enteral feeding, birth-related Aggressive enteral feeding, birth-related

hypoxic-ischemic insults, infectionhypoxic-ischemic insults, infection

NECNEC

Radiological appearanceRadiological appearance– Dilated loopsDilated loops– Pneumatosis intestinalis (present in 75%)Pneumatosis intestinalis (present in 75%)– Biliary tract airBiliary tract air– Pneumatosis gastralisPneumatosis gastralis– Free air (only present in 50-75% with perf)Free air (only present in 50-75% with perf)

Labs not diagnosticLabs not diagnostic

Treatment?Treatment?

NEC ManagementNEC Management

Consult peds surgeryConsult peds surgery AdmissionAdmission NPONPO NG/OGNG/OG Careful fluid/lyte mgmt (3Careful fluid/lyte mgmt (3rdrd spacing) spacing) ±Abx (amp/gent/flagyl)±Abx (amp/gent/flagyl)

NEC Take-home PointsNEC Take-home Points

90% are premature90% are premature Usually early but can be >3mo in VLBWUsually early but can be >3mo in VLBW Pneumatosis intestinalis specific for Pneumatosis intestinalis specific for

NECNEC Admit, NPO, Fluids, NG, Admit, NPO, Fluids, NG, ±Abx, ±Abx,

±Surgery±Surgery

Questions?Questions?

Quick Snapper #2Quick Snapper #2 6d F “off-colour” x 1-2 days - ?jaundice6d F “off-colour” x 1-2 days - ?jaundice Born 38Born 3866, uncomplicated delivery via C/S, uncomplicated delivery via C/S Feeding well, 10 wet diapers, 3 stool/dFeeding well, 10 wet diapers, 3 stool/d Wt – regained birth weight todayWt – regained birth weight today No fever, lethargy, irritabilityNo fever, lethargy, irritability FHx: nothing metabolic/congenitalFHx: nothing metabolic/congenital O/EO/E

– Well-looking child, VS NWell-looking child, VS N– Slight jaundiceSlight jaundice

Investigations?Investigations?

Quick Snapper #2Quick Snapper #2

CBC NCBC N Total bili = 200Total bili = 200μμmol/Lmol/L Conjugated bili not elevatedConjugated bili not elevated U/A –veU/A –ve

What now?What now?

JaundiceJaundice

Indications for further work-up?Indications for further work-up?– Jaundice appearing <24h after birthJaundice appearing <24h after birth– Elevated conjugated biliElevated conjugated bili– Rapidly rising total serum bilirubinRapidly rising total serum bilirubin– Total serum bilirubin approaching Total serum bilirubin approaching

exchange level or not responding to exchange level or not responding to phototherapyphototherapy

– Jaundice persisting beyond age 3 weeksJaundice persisting beyond age 3 weeks– Sick-appearing infantSick-appearing infant

Rosen’s

Neonatal JaundiceNeonatal Jaundice

HUGE differentialHUGE differential

What does this infant have?What does this infant have? Physiological jaundicePhysiological jaundice

– 60% incidence 160% incidence 1stst week of life week of life– Gradual bili increase until 3Gradual bili increase until 3rdrd day of life day of life– Bili returns to N ~2wksBili returns to N ~2wks– Why does this happen?Why does this happen?

Quick Snapper #2Quick Snapper #2

6d F6d F Jaundice, otherwise well-lookingJaundice, otherwise well-looking Bili 200Bili 200 Urine -veUrine -ve ?Physiologic jaundice?Physiologic jaundice

Management?Management?

Neonatal Jaundice Neonatal Jaundice ManagementManagement

Continue breastfeedingContinue breastfeeding MonitoringMonitoring

– Homecare, FPHomecare, FP ±Phototherapy±Phototherapy ±Exchange transfusions±Exchange transfusions

Complications?Complications?– Neurotoxicity, encephalopathy, Neurotoxicity, encephalopathy,

kernicteruskernicterus

Neonatal Jaundice Take-home Neonatal Jaundice Take-home PointsPoints

60% will get physiologic jaundice60% will get physiologic jaundice Conjugated hyperbili is pathologicalConjugated hyperbili is pathological Jaundice in first 24h of life is Jaundice in first 24h of life is

pathologicalpathological Know indications for further W/UKnow indications for further W/U

The EndThe End

Questions?Questions?