Diseases, Disorders information

Infant history: feeding history is obviously very important. Breast feeding versus bottle. It’s hard to make a diagnosis of early breast mild jaundice or late breast milk jaundice if the baby is bottle feeding. The important thing too – I’m being kind of facetious – but early breast mild jaundice, I will see kids who are admitted to the hospital with bilirubins of 23 or something like that at four or five days of age, and people are quick to jump to the diagnosis of early breast milk jaundice. You need to have data that is consistent with that. Mother should have some sense that she doesn’t have enough milk, she doesn’t feel let down, she doesn’t feel engorgement. And also you should have some objective evidence that the baby is not feeding well. So what you want to see is some moderate decrease in weight, perhaps greater than 10% in the first week of life. A baby that is thriving, feeding well, don’t jump to the diagnosis of early breast milk jaundice if they are presenting with a good feeding pattern. Vomiting history is very important and stooling pattern. Again, anything that is going to increase transit time through the gut is going to cause unconjugated hyperbilirubinemia. Generic cialis pharmacy news
Physical examination: bruising hematomas are important to look for. Hepatosplenomegaly may be suggestive of hepatitis. Plethora indicative of polycythemia, and then if you are thinking about TORCH infections, look for other signs. Baby may be small for gestational age, microcephalic, may have findings of pneumonia as well or ocular abnormalities, a bunch of different signs that you may see with congenital infection, and then I keep mentioning sepsis, signs and symptoms of sepsis should be watched for.
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Screening lab tests: if you have an indirect hyperbilirubinemia probably the most reasonable panel to get would include a CBC, a peripheral smear to look for evidence of hemolysis. Also reticulocyte count to look for evidence of hemolysis. You have to be a little bit careful. If you get it on the first day of life it’s not unusual to see fairly high reticulocyte counts because of the kind of charged up marrow with the stress of delivery. So I bet you can see reticulocyte counts in the 5-10% range in the first day or so of life, but those should drop fairly quickly in the next day or so. A type and Coombs is worth doing even if the mother is not O because you may have some of those minor antigens. And then one test that you might want to consider, if you can’t find an obvious source of hemolysis and bilirubins are getting to fairly high level, is a urinalysis. The importance of urinalysis is that you are looking for a positive Clinitest which will be seen with galactosemia. So here in California we have the newborn screening for galactosemia and that may not get back in the first few days of life, though. So you can’t be certain, in the first few days of life, that you are not dealing with galactosemia.
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Direct hyperbilirubinemia: screening tests, liver enzymes, AST, ALT, TORCH or septic workup if the diagnosis is suggestive on history and physical exam. Then a first test, in terms of looking at the liver and biliary tree, is probably an ultrasound. It’s probably the way to go. Now why all this fuss about bilirubin? Why do we worry about it? Of course the main reason we are concerned about it is kernicterus, which is staining of the basal ganglia with bilirubin. Acute symptoms – I think people are fairly familiar with the late sequelae of mental retardation, deafness and choreoathetoid CP. Again, a very important link, if they tend to mention choreoathetoid CP on the Boards they are probably thinking of kernicterus. Acute symptoms are important to know as well, and I think are not always as well known by people and those are primarily neurologic symptoms. So you’ll see lethargy, oftentimes decreased tone, often can see a very high-pitched cry and irritability, poor feeding and vomiting, GI symptoms may be present and then eventually it will lead to increased tone. You may see seizures and also opisthotonic posturing as well. Another thing to mention I think is that there is some evidence, even if we don’t have kernicterus – and it’s very rare to see kernicterus these days – that if you get bilirubins to moderately high levels, probably 20 and above, you may knock a few I.Q. points off. So my sense is that even though we tend not to worry about kernicterus that much in breast milk jaundice or breast feeding jaundice, I think I’m not completely willing to blow it off and say, “Okay, we don’t have to follow a baby with a bilirubin of 20.” I do try to intervene and keep bilirubins relatively low.
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