Presentation on theme: "Dr.Hisham Ahmed,M.D,MRCS.Eng Asst.Professor of General & Pediatric Surgery B.U.H2015."— Presentation transcript:
Dr.Hisham Ahmed,M.D,MRCS.Eng Asst.Professor of General & Pediatric Surgery B.U.H2015
Physiologic jaundice is the normal elevation of unconjugated bilirubin in healthy neonates. It usually manifests in the 1 st week of age. In white and black infants the peak level of bilirubin is ~ 6mg/dl at 72 hours of age. In Asian infants the bilirubin level peaks later (3-5 days) at a higher level (~12mg/dl). In preterm neonates, the level is ~12 mg/dl on the 5 th day of life. What is NPJ?
Phase one Term infants - jaundice lasts for about 10 days with a rapid rise of serum bilirubin up to (12 mg/dL). Preterm infants - jaundice lasts for about two weeks, with a rapid rise of serum bilirubin up to (15 mg/dL). Phase two bilirubin levels decline to about (2 mg/dL) for two weeks, eventually mimicking adult values. Preterm infants - phase two can last more than one month. Exclusively breastfed infants - phase two can last more than one month This pattern of hyperbilirubinemia has been classified into two functionally distinct periodshyperbilirubinemia
Decreased hepatic uptake e.g. Gilbert syndrome (unconjugated hyperbilirubinemia). Decreased conjugation e.g. Crigler- Najjer syndrome I/II (conjugated hyperbilirubinemia); Lucey-Driscoll syndrome; hypothyroidism; pyloric stenosis. Increased Enterohepatic circulation breast feeding, breast milk Cont.
Blood type/Rh Coombs’ test ( Direct Anti-globulin Test i.e. DAT). CBC Total and direct bilirubin level. LFT, PT and PTT if direct hyperbilirubinemia is present. Basic laboratory work-up of healthy newborn with increased unconjugated hyperbilirubinemia
MANAGEMENT; The American Academy of Pediatricians (AAP) published the following guidelines for phototherapy and exchange transfusion in 1994. Total bilirubin levels are expressed in mg/dl. AGEPHOTOTHERAPY EXCHANGE TRANSFUSION+ INTENSIVE PHOTOTHERAPY 1-2 days ≥ 15≥ 25 3 days ≥ 18≥ 30 >3 days ≥ 20≥ 30 N.B; Jaundice in a newborn ≤ 24 hours of age is considered pathologic and requires at least a total serum bilirubin level and possibly other laboratory tests for detection of hemolysis or other disease process
What is the difference between breast-feeding jaundice and breast- milk jaundice? Breast feeding jaundice Breast milk Jaundice Early onset Caused by the baby not getting enough milk and is not related to breast milk jaundice. Adequate amounts of breast milk increase a baby’s bowel movements, which help to wash out the buildup of bilirubin. late onset (jaundice that persists after physiologic jaundice subsides) Results from chemical changes in the milk that increase Enterohepatic circulation. Tends to be genetic and run in families. N.B; up to 4% of all breastfed infants have a serum bilirubin concentration> 10 mg/dl at 3 weeks of age.
What is the rule of thumb? It’s a notoriously inaccurate rule used to roughly estimate the approximate bilirubin level; BODY PART BILIRUBIN LEVEL (mg/dl) Face 6 Neck to the umbilicus 9 Umbilicus to knees 12 Knees to ankles 15 Hands and feet >15
Does NPJ affect the decision for Circumcision?
T.Bilirubin level less than 10mg /dl+ normal BT & CT+ negative DAT in a generally health baby……. DO Circumcision. T.Bilirubin level 11-15mg /dl+ normal BT & CT+ negative DAT……. DO Circumcision. T.Bilirubin level 15mg/dl or more postpone circumcision until jaundice is clinically and laboratory resolved( even if the other mentioned parameters are normal). T.Bilirubin level normal + abnormal BT&CT + negative DAT….. postpone circumcision, and correct the bleeding diathesis. ALL parameters are normal except DAT positive postpone circumcision and investigate for auto-immune hemolytic anemia. Protocol for neonatal circumcision
AAP, "Circumcision Policy Statement". Peds, Mar 103(3):686-693, 1999.Circumcision Policy Statement Elder, J. "Circumcision". BJU Int, Jun 99(6): 1553-1564, 2007. Eroglu, E, et al. "Buried penis after newborn circumcision". J Urol, Apr 181(4): 1841-1843, 2009.Buried penis after newborn circumcision Hutcheson, JC. "Male neonatal circumcision: indications, controversies, and complications". Urol Clin N Amer, Aug 31(3): 461-467, 2004.Male neonatal circumcision: indications, controversies, and complications Lerman, SE and JC Liao. "Neonatal circumcision". Ped Clin N Amer, 48(6):1539- 1557, 2001. Niku, SD, et al. "Neonatal circumcision". Uro Clin N Amer, 22(1): 57-65, 1995. http://www.circumcision.net/jaundice.htm References