Neonatal jaundice is the most common neonatal disease, and many people will think that jaundice is a self-limiting disease without much intervention. In fact, many children who see jaundice are not as simple as they think, and the harm is unexpected. The following case fully illustrates this point.
Zheng XX, from Xushui District, Baoding City, Hebei Province, female, 8 days old, Manchu, first birth of the first child, gestational age 38+ 5 weeks, born on 2021-02-19 14:31 due to intrauterine development limitation by caesarean section. Birth weight 2.62Kg. Maternal blood type "A", Rh (+), paternal blood type O, child blood type A, Rh (+). Breastfeeding, adequate milk intake, about 3 hours after birth, the first discharge of fetal stool, the amount is large, about 48 hours after birth, the stool gradually turns yellow.
The mother did not have premature water breakdown, the umbilical cord, amniotic fluid, and placenta were normal, and a history of asphyxia and amniotic fluid inhalation was denied. Heel blood has been collected. Her mother was in good health during pregnancy and had regular obstetric examinations. At 32 weeks of pregnancy, the ultrasound found that the fetus was 1 week smaller than the fetus of the same gestational age, and 2 weeks smaller at 34 weeks.
Physical examination: the newborn's appearance, normal reaction, yellow-white skin mucosa, no bleeding spots, petechiae, ecchymosis, no rash. There is no deformity in the skull, no scalp hematoma, the anterior fontanelle is flat, and the tone is not high. The sclera is yellow stained, and yellow discharge is visible in both eyes. The cord is not shed, there is no bleeding and exudation, and there is no congestion of the umbilical chakra. Tender abdomen, untouched under the ribs of the liver and spleen.
Outpatient measurement of percutaneous bilirubin: head/chest 12.7/17.6 mg/dl.
The main purpose of the family with the child is to measure the jaundice value!
This is not a particularly high percutaneous jaundice value, does it really not require special intervention?
In view of the child's yellowish-white skin color and anemia, he repeatedly communicated with the family and checked the venous blood routine and liver function. Returns: Hemoglobin 136g/L, total bilirubin 248.1umol/L, indirect bilirubin 235.08umol/L.
Suggests that hyperbilirubinemia and anemia are not very severe, but they are present at the same time, and further progression is required and active search for causes. The process of mobilizing for hospitalization was not very smooth, but in the end, the family still "endured" and left the child in the neonatal ward.
1. The treatment process after hospitalization
Special care of the neonatal department, intensive care, incubator warmth, monitoring of ECG and oxygen saturation, low-weight formula feeding, monitoring of weight gain. Intermittent blue light exposure dehubarbing, oral vitamin B2 supplementation with riboflavin, bifidobacterium tetracycline tablets to regulate the intestinal flora, oral phenobarbital tablets to induce liver enzyme activity.
A and Rh positive deblanting suspension of red blood cells (40 ml each time, a total of 2 times) and oral iron, folic acid tablets, vitamin B12 tablets to correct anemia treatment. After a total of 12 days of treatment, the child's skin color turned red, anemia was corrected, jaundice subsided, and he was discharged from the hospital.
Second, during the hospitalization process, the changes in auxiliary examinations
Blood count, CRP, and reticulocytes suggest
Hemoglobin progressively decreases until 83 g/L, and after transfusion, hemoglobin is elevated and stable (105 for 3-03HB in the table below).
Peripheral blood smear
Peripheral blood nucleated cells are dominated by lymphocytes; red blood cells vary in size mildly, occasionally acute red blood cells; platelets are not uncommon. Neutrophils 37%, neutral rod cells 0, eosinophils 4%, lymphocytes 51%, monocytes 8%.
Liver function tests suggested
Bilirubin remains elevated, showing a slow decline, and is always dominated by indirect elevation of bilirubin.
Hemolytic disease test
Neonatal blood group A (+), negative for direct antiglobulin, negative for free IgG antibodies, negative for erythrocyte-released IgG antibodies. Negative anti-erythrocyte irregular antibodies.
There were no abnormalities in the five items of Jia Gong.
TORCH saw no abnormalities.
Eight items of infection were not abnormal.
No abnormalities were seen in the urinalysis. No abnormalities are seen in the stool routine.
No bacterial growth is seen in blood cultures.
Imaging studies
Abdominal ultrasound - abdominal ultrasound: the size of the gallbladder after a meal is about 2.3 cm×0.5 cm, and no obvious abnormalities are seen in the liver, spleen and kidneys.
Percutaneous bilirubin assay
3. Final diagnosis
1. Neonatal hyperbilirubinemia; 2. Neonatal anemia (severe); 3. Intrauterine growth restriction; 4. Atrial septal defect.
4. Follow-up and transfer
3 days after discharge, the jaundice subsided, the hemoglobin was stable, and the oral vitamin D2, dextran iron oral solution, folic acid tablets, vitamin B12 tablets continued. Monitor weight gain weekly.
5. Summary and experience
The co-existing causes of jaundice and anemia are most common in hemolysis, blood loss, and infection.
hemolysis
The most common hemolysis is immune haemolysis due to maternal and infant blood group incompatibility, and the mother's blood type is A (+).
Newborn hemolytic disease testing
Direct reaction, free, and release tests are all negative, and anti-erythrocyte irregular antibodies are negative, so immune hemolytic jaundice caused by blood group incompatibility is not supported.
Hemolytic diseases caused by special causes include G6PD enzyme deficiency, pyruvate kinase deficiency, hereditary spheroid erythrocytosis, thalassemia, etc., and the diagnosis is mainly based on specific tests combined with family history.
Evidence of blood loss is absent and may be excluded.
Jaundice and anemia caused by infection are divided into intrauterine infection and extrauterine infection, more common in TORCH virus, microvirus B19, etc., mother infection virus through the placenta transmission, anemia, thrombocytopenia, the most common is CMV infection, more developmental delay, postnatal growth retardation, liver damage, blood system, nervous system symptoms, the child CMVIgM negative, no liver function and other multisystem damage, not supported. There is insufficient evidence of bacterial infection and is not supported.
Combined with the symptoms, signs and auxiliary examination of the child, our hospital conducts an exclusionary diagnosis of the etiology, gives symptomatic support and treatment, close observation, communicates with the family, and recommends further genetic testing to determine the cause.
Neonatal jaundice is the most common neonatal disease with complex etiology and can cause serious consequences such as bilirubin encephalopathy. Intervention should never be judged solely on a single bilirubin value.
According to the child's gestational age, day age, weight, the time of jaundice, the speed of progression, whether there is maternal and infant blood type incompatibility, sepsis, anemia, preterm birth, low birth weight and other high-risk factors to conduct a comprehensive assessment.
If neonatal jaundice appears prematurely, persistently does not regress, recurs, progresses too quickly, and combines risk factors, it is often necessary to go to the hospital for treatment, and it is not simply believed that neonatal jaundice is a physiological phenomenon without any harm, waiting for it to subside on its own.
Source: Pediatrics Channel of the Medical Professions
Edited by: Yeah Reviewer: Xiao Ran