Nota Perubatan

Category: Paediatrics

  • Prolonged Neonatal Jaundice (NNJ)

    Introduction

    The main aim of management / monitoring of prolonged NNJ is exclusion of conjugated hyperbilirubinaemia, especially biliary atresia (early diagnosis & biliary drainage will give successful long-term good bile flow in >80% of children; good bile flow is achieved only achieved in 20 – 30% children if surgery is late)

    Definition

    Very important to know the definition to avoid wrong treatment to patients with NNJ

    Prolonged NNJ

    Prolonged NNJ = Visible jaundice (serum bilirubin >85 µmol/L) that persists beyond 14 days of life in term baby (≥37 weeks) or 21 days in a preterm baby (≥35 to <37 weeks)

    Conjugated hyperbilirubinaemia

    Conjugated hyperbilirubinaemia = Conjugated bilirubin >34 µmol/L or more than 15% of total bilirubin
    Note: Conjugated hyperbilirubinaemia is NEVER normal / physiologic

    Causes of Prolonged NNJ

    Unconjugated hyperbilirubinaemia

    • Septicaemia, UTI, breast milk jaundice, hypothyroidism
    • Haemolysis (e.g. G6PD deficiency, congenital spherocytosis)
    • Galactosaemia
    • Gilbert syndrome

    Conjugated hyperbilirubinaemia

    • BIliary tract abnormalities: biliary atresia, choledochal cyst, paucity of biliary ducts, Alagille syndrome
    • Idiopathic neonatal hepatitis
    • Septicaemia
    • UTI
    • Congenital infection: TORCHES
    • Metabolic disorders e.g. citrin deficiency, galactosaemia, alpha-1-antitrypsin deficiency
    • Total parenteral nutrition – induced cholestasis

    Monitoring / Management of Prolonged NNJ

    Important history

    • Any pale stool / dark urine?
    • Feeding: Breastfeeding / Bottle feeding / Mixed?
    • Any poor feeding?
    • Any fever / rapid breathing at home?

    Examination

    • Septic or ill looking? Lethargy?
    • Signs of respiratory distress? (e.g. tachypnoeic, chest recession, desaturation)
    • Perfusion: good / poor?
    • Weight monitoring (good / poor weight gain)
    • Any hepato / splenomegaly?
    • Diapers inspection (dark yellow urine, pale stool)

    Laboratory tests

    • Cord TSH (should have been done at birth)
    • G6PD (should have been done at birth)
    • FBC, reticulocytes
    • UFEME
    • Serum bilirubin — direct, indirect
    • Thyroid function test (FT4, TSH)
    • Certain centers will also send FBP (full blood picture) to look for haemolysis as well as LFT + AST

    Other tests (if indicated)

    • Serum gamma glutamyl transpeptidase (GGT), to differentiate obstructive VS non-obstructive causes of neonatal hepatitis. Significantly elevated GGT (few hundred) with pale stool strongly suggest biliary obstruction
    • Ultrasound hepatobiliary system (HBS)

    Appendices

    Flow Chart Management of Prolonged NNJ in Babies ≥35 Weeks
    Workups for conjugated hyperbilirubinaemia

    Important Messages

    • Conjugated hyperbilirubinaemia is NOT normal
    • Refer Paediatrician if high or moderate risk prolonged NNJ / conjugated hyperbilirubinaemia / jaundice more than 2 months / SB >300 µmol/L or other abnormal lab result

    References

    1. Paediatric protocol 4th ED (2019)
    2. Integrated Plan For Detection & Management of Neonatal Jaundice 2nd ED (2017) [Download]
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