Diseases, Disorders information

Late breast milk jaundice, you really… all you need to do is make sure there is no hemolysis. And generally what we do is just stop breast feeding for 24 hours and if the bilirubin drops - usually you’ll see at least a 2-3 point drop in 24 hours - then you can just go ahead and restart breast feeding and it seems to be absolutely safe and the jaundice will disappear after a few weeks. Discount prozac news
On the direct hyperbilirubinemia, fortunately the list for direct for hyperbilirubinemia is a shorter risk. Number one cause is hepatitis. A bunch of different infections that you may see. But certainly TORCH infections all can present with hepatitis. Also there is idiopathic or giant cell hepatitis as well as sepsis that can cause a direct hyperbilirubinemia. Second is cholestasis. There is a slight error on this slide. Under intrahepatic you see arteriohepatic dysplasia and the Alagille syndrome. Those two are the same thing. They shouldn’t be listed separately. Intrahepatic or arteriohepatic dysplasia, Alagille syndrome, is an interesting problem. Again, one of those things that might well show up on the Board. It has a combination of facial abnormalities, with deep-set eyes, broad forehead, and this prominent or triangular-shaped chin. Also has a paucity of intrahepatic bile ducts and then also peripheral pulmonic stenosis. So it’s one of those things that if you see a cholestatic baby they have a murmur, what’s the likely one if they have these facial abnormalities; peripheral pulmonic stenosis is the cardiac lesion that you will see.
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Extrahepatic biliary problems: biliary atresia doesn’t present in the first week of life. And you would think that biliary atresia should, if they don’t have a functioning bile duct it would produce jaundice. But generally what you see is these babies present more at 3-6 weeks of age and sometimes the diagnosis can be delayed after that. Other bile duct problems: you can see choledochal cysts, also extrinsic compression of the bile duct, perhaps pancreatic in origin, and then bile ducts can all produce hypobilirubinemia.
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A couple of inborn errors that you need to be aware of. These are ones that you just have to memorize. There is no easy way of remembering these. Dubin-Johnson and Rotor’s, and then again as we mentioned before, galactosemia, tyrosinemia and then endocrine problems, hypothyroidism and hypopituitarism can all produce a direct or conjugated hyperbilirubinemia.
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So on to the evaluation of the jaundiced newborn. History, as is usual, is really a crucial factor and things that you may want to look at in the maternal history; diabetes, you may see polycythemia in infants, infections -were there any signs of infection in the first or second trimester that make you think that this mother may have had a TORCH infection? Medications, drugs that may produce hemolysis in G6PD. There is obviously a very long list that you may want to look at before you take the Boards, but the most important ones are things like sulfas or nitrofurantoin and are drugs that are fairly commonly taken by mothers, even during pregnancy. Also if you see fava beans mentioned anywhere, that link is G6PD so I’m not sure a mother would eat fava beans before delivering, but if it happens to show up in the history that would be of concern. Birth trauma; if there is a reason this baby will have a cephalhematoma. Risk factors for sepsis though, again, septic babies, jaundice is not going to be a presenting sign of sepsis. Family history is very important in jaundice. Any of the inherited causes, so things like spherocytosis or elliptocytosis, some of the conjugating or enzyme deficiencies, Gilbert’s, Crigler-Najjar, family history may be important. History of anemias, some of the hemoglobinopathies, and again, structural problems such as elliptocytosis and spherocytosis may see a positive family history. Splenectomy can be suggestive of spherocytosis. Again, spherocytosis and elliptocytosis, structural problems, are autosomal dominant so you may have a very positive family history. If there are people who have had splenectomy, think about those structural problems as a possible cause of jaundice. Then siblings with jaundice, you need to think about some of the autosomal recessive disorders.