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JAUNDICE -
INVESTIGATION OF PROLONGED NEONATAL JAUNDICE
Definition
Prolonged jaundice = Jaundice persisting for more than 14 days.
Children with clinically apparent jaundice present after 14 days of life require:
1) Clinical review including examination of stool colour
2) Conjugated and total bilirubin measured
Any delay in follow-up for children with neonatal jaundice can lead to poor long term outcomes.
Primary investigation of prolonged jaundice will include: feeding history, examination of the baby,
examination of stool colour (acholic stools are highly characteristic of cholestasis in infancy). Initial
laboratory tests should include: Bilirubin (total & direct (conjugated)), Urine (for infection and
reducing substances), FBC and possibly a G6PD screen. Bilirubin fractionation is the most
important test in any infant who has more than two weeks of jaundice.
Unconjugated
Unconjugated Hyperbilirubinaemia
Total conjugated bilirubin < 20 umol/L and
Conjugated bilirubin <20% total bilirubin
Children with unconjugated hyperbilirubinaemia require assessment for underlying diagnosis and
therapy.
Important issues
1) Clinical assessment sepsis
2) Does the child require phototherapy?
3) Urine for Dipstick +- culture?
4) Consider FBC and film/ G6PD/ Coombs for haemolysis
5) Review maternal blood group for ABO/ rhesus incompatibility
Conjugated Hyperbilirubinaemia
Hyperbilirubinaemia
Total conjugated bilirubin > 20 umol/L or
Conjugated bilirubin >20% total bilirubin
Any patient with conjugated hyperbilirubinaemia will be urgently reviewed by the Paediatric
Gastroenterology/Hepatology service.
JAUNDICE -
INVESTIGATION OF PROLONGED NEONATAL JAUNDICE
Important clinic issues
1) Most children with conjugated hyperbilirubinaemia look well but may have important
disease.
2) Stool colour pale stool and dark urine suggests Biliary Atresia
3) All children with conjugated hyperbilirubinamia require additional Vitamin A,D,E,K
NeimannPick type C
Wolmans disease
Peroxisomal disorders
Congenital disorders of
glycosylation
Infections Toxic DubinJohnson syndrome
Septicaemia Rotor syndrome
Urinary tract infection Parenteral nutrition Aagenaes syndrome
TORCH infections Citrin deficiency
(toxoplasmosis, rubella, Chloral hydrate Fatty acid oxidation disorders
CMV, herpes viruses) Foetal alcohol syndrome Mitochondrial disorders
Human Herpes virus-6, Transaldolase
Varicella-zoster GSD IV
HIV, Hepatitis B Mevalonic acidemia
Echo, Adeno, Coxsackie- Hereditary Fructose
virus Intolerance
Parvovirus, EBV
JAUNDICE -
INVESTIGATION OF PROLONGED NEONATAL JAUNDICE
Liver Biopsy
Yes
Biliary Atresia
Kasai
Note:
JAUNDICE -
INVESTIGATION OF PROLONGED NEONATAL JAUNDICE
T4 and TSH
Ferritin
Cholesterol / triglycerides
Cortisol
Urine CMV
Liver Ultrasound
JAUNDICE -
INVESTIGATION OF PROLONGED NEONATAL JAUNDICE
Date Result
Plasma ammonia
Plasma Lactate
Adenovirus serology
Stool Enterovirus
Parvovirus PCR
HHV6 PCR
HIV
Spine x-rays
Ophthalmology review
Urine calcium/Phosphate
creatinine ratio
Sweat test
JAUNDICE -
INVESTIGATION OF PROLONGED NEONATAL JAUNDICE
Date Result
Metabolic review-
Acyl-Carnitine profile
Karyotype
Short synacthen
CSF Lactate
JAUNDICE -
INVESTIGATION OF PROLONGED NEONATAL JAUNDICE
Interventions
All infants with conjugated hyperbilirubinaemia are started on Vit A, D, E, K
Early consideration for starting MCT based formula (peptijunior)
Vitamin A
Available preparation: Vitadol C = 2000 micrograms vitamin A per gram = 1 ml =7500 IU
Starting dose is 1ml once daily
NB: Vitadol C is only partially subsidised in the community; families should be informed
they will be required to pay a part charge for this medicine.
Vitamin D
Starting dose = 3050 nanograms/kg once a day rounded to nearest 100 nanograms
Available preparation = Alfacalcidol (One-Alpha drops) = 100 nanograms of 1-alpha-OH
vitamin D3 per drop.
NB: This preparation should be prescribed in drops.
Vitamin E
Starting dose = 50 mg (68 IU) once a day.
Available preparation = d-alpha-tocopheryl acetate (Micelle E) = 156 IU/ml
Suggested dose is therefore 0.5 ml once daily.
NB: SPECIAL AUTHORITY is required for vitamin E administration and will be completed
by the childs paediatrician prior to the child leaving hospital.
Vitamin K
Suggested dose = 2.5 mg once a day
This is of an adult 10 mg Konakion tablet which can be crushed and mixed with water
References
Mckiernan P. Neonatal cholestasis. Seminars in Neonatology. 2002 7 (2): 153 - 165