Neonatal jaundice

Neonatal jaundice typically occurs on day 2- 3.

ALL JAUNDICE IN FIRST 24 H IS PATHOLOGICAL.

Risk factors

• Prematurity
• Low birth weight
• Peri-natal hypoxia / hypoxia
• Cephalhaematoma/bruising
• Sepsis
• Blood group incompatibility
• Polycythaemia
• Inadequate feeding
• Delayed passage of meconium

Aetiology of NNJ

• Physiological 
• Breakdown of fetal rbc
• Inadequate conjugation due to low levels of hepatic enzyme glucuronosyltransferase
• Inadequate conversion to urobilinogen by intestinal flora
• Prematurity
• Haemolysis - ABO, G6PD, Rh, hereditary spherocytosis, drug-induced, polycythaemia, cephalhaematoma
• Infection - intrauterine infection, UTI, sepsis
• Metabolic - hypothyroidism, inborn errors of metabolism, insulin dependent diabetic mother, hypoglycaemia
• Breastmilk jaundice

Aetiology of Prolonged NNJ (Beyond 15 to 21 days)

• Neonatal hepatitis
• Obstructive jaundice - biliary atresia, choledochal cyst, duct hypoplasia 
• UTI
• Hypothyroidism
• Breastmilk jaundice

ADMIT:

1) SB at phototherapy exchange levels

2) Babies > 14 days with any of :

• Antenatal/birth history suggestive of intrauterine infections
• History of feeding problems, vomiting
• Recurrence of jaundice after initial improvement
• Pale stools, dark urine
• Physical findings of deep jaundice, rashes, cataract, pallor, hepatosplenomegly, microcephaly, cardiac murmurs, abnormal neurological examination

There is no benefit of phototherapy for babies with jaundice > 14 days of life. 

If baby is >14 days of life, consider 

• Direct/Total SB
• check cord TSH ( aim <20 umol/L)
• no need routine UFEME

Admitting criteria for NNJ

Low-risk vs high-risk (2 different cut off SB levels, refer to table)

High- risk:

• Jaundice in first 24H
• Blood group incompatibility with DCT or antibody titre > or equal 128
• G6PD
• Gestational age 35-36 wks at birth, <7 days of age
• Significant cephalhaematoma, bruising
• Exclusive breastfeeding, if not nursing well ( Weight loss >10% from birth weight, dehydrated, less than 5 wet diapers/day)
• <72H and mother O+ with baby A/B/unknown
• Rise in SB > 85umol/L in 24H

vs

Low-risk

No known high-risk factors

Clinically well

REFER TO OPS FOR REVIEW:

1) Majority of babies with physiological jaundice < 14/7 and none of the above abnormal features

2) If SB is on downward trend or downward trend is to be expected

• physiological jaundice is maximum on D3-D5 in term infants and D5-6 in prems, and disappears by D7 in terms and D9 in prems.

REFER TO PAEDS MED FOR REVIEW:

1) Direct SB< 15% total, child well and asymptomatic, TCU 1/52

2) If direct/total SB>15% and direct SB > 35% can get early TCU, will need phenobarb priming and HIDA scan

3) KIV admit if baby > 3/52 old so Ix can be done in the ward.

BILIARY ATRESIA MUST BE RULED OUT AND OPERATED ON BY 6 WEEKS OF LIFE.

NNJ discharge advice

• Ensure hydration and good feeding and normal bowel movement
• Return if febrile, vomiting, poor feeding 
• Sunning baby is not effective and may lead to sunburn and dehydration
• No treatment is required but will need careful assessment at SOC / OPS TCU

The crying baby

HISTORY

• Trauma
• Fever
• Vomiting
• Breathlessness
• AMS
• Feeding
• Crying/consolability
• Medication
• Immunizations
• Mothercraft  (young mother, improper feeding/burping technique, sarong)

EXAMINATION

• Vitals 
• Irritability, abnormal cry (post DPT, meningitis, neonatal abstinence syndrome, infantile spasms)
• General appearance - toxic, lethargic
• Head - bulging fontanelles (raised ICP), facial brusing (NAI), cephahaematoma (HI)
• Ears - Otitis media
• Eyes - Fundus - retinal haemorrhage, FB, corneal abrasion (fluorescein stain) 
• Abdo - distension, masses, tenderness e.g. (intussusception, IO, pyloric stenosis), anal fissure (GE), KIV PR if bloody stool
• GU - ENSURE EXPOSURE COMPLETE. Genitalia for torsion of testes, incarcerated hernia, haematuria, open diaper pin
• Extremities - stranged digit (hair tourniquet), bruising (NAI)
• Skin - bruises, stigmata of NAI

INVESTIGATE

KIV

- UFEME

- FBC

- AXR (intussusception, volvulus)

- CXR (SVT, ischaemia)

- ECG

What is infantile colic?

• Occurs in 2nd to 3rd wk of life
• Most resolve by 3/12
• Lasts several hours each time, commonly late afternoon, evening, with flatus
• May be due to immature GIT, poor feeding technique, CNS, ?cows milk injury, not enough burping, suckling, parental anxiety, baby's temperament

Treatment of infantile colic:

• Reassurance
• Rocking, car rides
• Infacol 8 drops pre feed

Indication for admission

• History/Ex suggestive of physical illness, esp poor feeding, vomiting, fever
• Abnormal UFEME, FBC, CXR, AXR
• First episode of acute onset in a previously healthy baby especially if they are outside the infantile colic age range
• 2nd presentation at ED
• Inconsolable after 1 hour in ED
• Parents anxious/cannot cope

Discharge information

• Reassure no obvious abnormality
• Bring baby back to ED /GP if crying worsens or if fever/vomiting/poor feeding
• Simple mothercraft
• No changing of milk formula necessary. May give infacol 

Paediatric Fever and Management

Defined as T>38C

Admit:
1) <3months old with fever/toxicity
2) Toxic in appearance (sepsis)
- lethargic (poor/absent eye contact, failure to recognise parents)
- poor perfusion
- hypo/hyperventilation
3) Fever > 7 days with no source
4) T>41C
5) Immunocompromised (chronic/cyclical neutropaenia, malignancy on chemo, high/chronic steroid, post splenectomy, post transplant)
6) Dengue, plt <80
7) Atypical/classical Kawasaki

Fever can be A) INFECTIVE or B) NON-INFECTIVE

Serious infective fevers
1) Meningitis
2) Pneumonia
3) UTI - admit those < 6/12 old
4) Dengue  or Malaria
5) Septic arthritis
6) Myocarditis, endocarditis

Serious non-infective fevers
1) Kawasaki
- Features: FEVER for >5 days, with 4 of the following 5 criteria

• Rash - polymorphous erythematous
• Non-suppurative conjunctivitis
• Cervical lymphadenopathy (1 node > 1.5cm)
• Oral mucosa changes e.g. cracked red lips, strawberry tongue, injected tonsils
• Skin changes e.g. periungal peeling, initial pedal and palmar swelling

- may be a/w leucocytosis/thrombocytosis from 2nd wk of illness

- early dx essential to prevent coronary artery thrombosis!

- Admit even if incomplete KD if suspicion high.

2) Malignancy

3) Collagen vascular disease

FEVER WITHOUT SOURCE?
- Well child with fever but no viable source on history/examination
- Most commonly viral or UTI in pre-verbal children. If prolonged, consider occult infection or non-infective causes.

INVESTIGATIONS
1) Urinalysis
- All fevers of unknown origin in preverbal child
- Fever with abdo pain, vomiting, min or no diarrhoea (preverbal child)
- Dysuria (verbal child)
- MSU or in-and-out catheter for urine C/S before starting antibiotics!
- Admit if WBC > 100hpf if child is <6/12

2) Full blood count
- Use for dengue -look for  thrombocytopaenia
- Tonsils with exudates - possible infectious mononucleosis- look for raised atypical lymphocytes
- Consider FBC if fever >5/7 . Consider FBC if fever without source  >3/7.
- Consider admission if :

• TW >20 k, ANC > 10k in <3yo
• TW >30k in >3yo
• If TW 20-30k or ANC <10k in child < 3yo, check with senior doctor

- Check with senior doctor before admission as some children may be non-toxic and can have PO Abx empirically outpatient

3) CXR

Use if 

• Fever with prolonged cough
• Tachypnoea
• Adventitious lung sounds
• Fever without source and TW > 20k

- Use if fever and cough  >5/7

- Occult pneumonia  = 26% prevalence

4) ECG

- TRO myocarditis

- Consider if tachycardia out of proportion to fever.

VIRAL FEVER is a diagnosis of exclusion!

MANAGEMENT

1) Conservative measures

• Thin clothing
• Tepid sponging/shower if T>38.5C
• Fluids and hydration
• Rest 

2) Medications

• PARACETAMOL
• Drug of choice
• 10-15mg/kg
• Toxic dose is 150mg/kg or 15x maximum dose
• Q6H
• Can use Q4H if T>39C
• Can give on empty stomach. Monitor temperature throughout the night.
• DO NOT PRESCRIBE IF <3/12 - MAY NEED ADMISSION IF FEBRILE

• NSAIDs
• Risk of GIT bleed, renal toxicity
• PO ibuprofen 5-10mg/kg Q6-8H
• Rectal Diclofenac (12.5mg) 1/2 supp Q12H if <2yo, or 1 supp Q8 to 12H if >2yo
• Only use rectal diclofenac if Hx of febrile seizures, or if caregiver insists (to document)
• DO NOT USE BOTH NSAIDS and PARACETAMOL for children <1yo
• Do not combine ibuprofen/diclofenac
• No evidence diclofenac superior to ibuprofen
• Combined use of paracetamol and NSAID
• No benefit/toxicity
• Can add on NSAID if temp still high
• Use paracetamol 4-6H as first line as it is safer
• If fever still increasing after paracetamol/tepid sponging/cold compress, then use NSAID PRN
• Use next dose NSAID 6H later
• Dosing is independent and not related to frequency of panadol

ANTI-PYRETICS ARE NOT A CURE FOR FEVER. Will not change the natural history of fever.

FEVER DISCHARGE ADVICE

- TO RETURN IF:

- Persistent fever at high level x 3-4/7 with no nadir

- Persistent vomiting, not feeding well

- Lethargic, drowsiness, irritability, poor headache

- Pale/blue

- SOB

- Fever without source > 3/7 (?atypical pneumonia, UTI)

- Fever persists >3/7 after antibiotics prescribed

- Not to resume strenuous activity till recovery - MC 5/7, excuse from PE 14/7