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Outpatient Care of the PostPartum Woman and her baby

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What are the risks to children when postpartum depression goes untreated? Children of mothers with untreated depression exhibit. More fussiness and colic – PowerPoint PPT presentation

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Title: Outpatient Care of the PostPartum Woman and her baby


1
Outpatient Care of the PostPartum Woman and her
baby
  • Sarah Gopman, MD
  • Associate Professor
  • Dept. of Family and Community Medicine
  • University of New Mexico
  • July 1, 2015

2
Learning/Practice Objectives
  • Screen for and treat postpartum depression
  • Evaluate and treat postpartum thromboembolic
    disease
  • Recognize and treat endomyometritis, c-section
    wound infections, and perineal wound
    complications
  • Manage breastfeeding difficulties
  • Evaluate and manage newborn hyperbilirubinemia

3
Screening for and Treatment of Postpartum
Depression
4
A postpartum patient at risk for depression
  • Josie is a 25 y/o woman cared for by you since
    she was 19
  • H/o major depressive d/o, including
    hospitalization for suicide attempt age 17
  • Intermittently on SSRI, stopped two months prior
    planned pregnancy, did well with cognitive
    behavioral therapy during pregnancy
  • Had a term NSVD of a healthy baby and is
    breastfeeding

5
What type of mood disorders occur in the
postpartum period?
  • Postpartum/baby blues
  • 40-80 of women affected
  • Feeling overwhelmed
  • Irritability
  • Tearfulness
  • Exhaustion
  • Trouble falling or staying asleep
  • Usually resolves by two weeks postpartum
  • Increased risk of developing full postpartum
    depression

6
What type of mood disorders occur in the
postpartum period?
  • Postpartum depression
  • 10-20 of women affected
  • Greatest risk is first 12 weeks after delivery,
    but risk persists for one year
  • Symptoms last more than 14 days

7
What are postpartum depression symptoms?
  • Tearfulness, sad or flat affect, irritability,
    mood instability
  • Feeling inadequate, guilty, overwhelmed
  • Sleep and appetite disturbance
  • Intense worries or obsessive thoughts re. harm to
    the baby
  • Difficulty concentrating or making decisions
  • Lack of interest in the baby, family or
    activities
  • Poor bonding
  • Thoughts of death or suicide
  • Somatic symptoms HA, CP, palpitations, numbness,
    hyperventilation

8
How is postpartum psychosis characterized?
  • 1-2 in 1000 women affected
  • Agitation and anger
  • Anxiety/Paranoia
  • Insomnia/Delirium/Confusion
  • Mania (hyperactivity, elated mood)
  • Suicidal or homicidal thoughts
  • Auditory hallucinations (about the baby, of a
    religious nature)
  • Visual hallucinations (seeing or feeling a
    presence or darkness)
  • Delusions and commands to harm the infant (not
    just an obsessive thought)
  • EMERGENCY PSYCHIATRIC HOSPITALIZATION NECESSARY

9
What is the risk of suicide in the postpartum
period?
  • Suicides account for up to 20 of all postpartum
    deaths and represent one of the leading causes of
    peripartum mortality. (2005 in Archives of
    Womens Mental Health)

10
What is different about postpartum depression
versus depression at other times of life?
  • Sleep deprivation is the norm postpartum
  • Strong societal expectations about maternal
    happiness postpartum
  • 50 of postpartum depression goes undiagnosed
  • Postpartum depression affects mothers, children,
    partners, and families

11
How does maternal depression relate to pregnancy
outcomes?
  • Maternal effects
  • Low weight gain
  • Increased use of cigarettes, alcohol, other
    substances
  • Ambivalence regarding the pregnancy
  • Neonatal/infant effects
  • Increased preterm birth
  • Low birth weight
  • Higher cortisol levels (sustained through
    adolescence)

12
How does postpartum depression affect maternal
behavior?
  • Mothers who are depressed show
  • Less affectionate behavior and impaired bonding
  • Less response to infant cues
  • More hostile/intrusive interactions with their
    infants
  • Decreased rates of infant safety practices

13
What are the risks to children when postpartum
depression goes untreated?
  • Children of mothers with untreated depression
    exhibit
  • More fussiness and colic
  • Impaired emotional development fewer positive
    facial expressions
  • Poorer language development less vocalization
  • Difficulties with attention
  • Decreased cognitive skills
  • Increased risk for long-term behavioral problems
  • Remission of maternal depression improves
    childrens mental and behavioral disorders
  • Consider depression during pregnancy and
    postpartum as an exposure with associated risks
    for the infant!

14
When should you screen your patient for
postpartum depression?
  • Any routine infant or maternal postpartum visit
  • Special visits scheduled for following up on hx
    of depression
  • Example
  • First newborn check at 2 or 3 days after d/c
  • 2 weeks postpartum
  • 4-6 weeks postpartum

15
What method will you use to screen her?
  • Postpartum Depression Screening Scale
  • 35-item Likert response scale (Strongly
    Disagree to Strongly Agree)
  • Third grade reading level
  • Completed by patient in 10 minutes
  • Addresses seven areas
  • Sleeping/Eating Disturbances
  • Anxiety/Insecurity
  • Emotional Lability
  • Cognitive Impairment
  • Loss of Self
  • Guilt/Shame
  • Contemplating Harming Oneself

16
What method will you use to screen her?
  • Edinburgh Postnatal Depression Scale
  • 10-item self-report scale (Yes, most of the
    time to No, not at all)
  • Each item scores 0-3 points, max score 30, gt10 is
    cutoff for depression
  • Available in several languages
  • Intended for use at 6-8 weeks postpartum, but
    validated for use at other times
  • Completed by patient in 5 minutes
  • Addresses symptoms of
  • Inability to laugh
  • Inability to look forward to things with
    enjoyment
  • Blaming oneself unnecessarily
  • Feeling anxious or worried
  • Feeling scared or panicky
  • Feeling that things have been getting on top of
    me
  • Difficulty sleeping because of unhappiness
  • Feeling sad or miserable
  • Crying
  • Thoughts of harming oneself

17
How do the two screening methods compare?
  • Postpartum Depression Screening Scale
  • For combined major and minor postpartum
    depression
  • sensitivity 91
  • specificity 72
  • Edinburgh Postnatal Depression Scale
  • For combined major and minor postpartum
    depression
  • Sensitivity 68-80
  • Specificity 77

18
Which antidepressants can be used while
breastfeeding?
  • Sertraline (Zoloft) currently favored SSRI during
    breastfeeding
  • Short half-life
  • Low or undetectable infant plasma levels
  • More follow-up data on infant development
  • Paroxetine (Paxil) and fluvoxamine (Luvox) also
    show low infant plasma levels
  • Use following with caution in patients w/ prior
    good effect
  • Fluoxetine (Prozac)--long half-life
  • Citalopram (Celexa)--high breast milk
    concentration

19
What else do we know about antidepressant use
while breastfeeding?
  • Omega-3 fatty acids showed significant response
    rate in one open-label study
  • Medication exposure to fetus via placental
    transfer is almost always greater than to the
    newborn via breastfeeding
  • Most national guidelines recommend six months of
    treatment once depression is in remission

20
What are non-pharmacological options for
treatment of postpartum depression?
  • Cochrane Review any psychosocial or
    psychological intervention, compared to usual
    postpartum care, is associated with reduction in
    risk of continued postpartum depression
  • Breastfeeding may be somewhat protective against
    postpartum depression (oxytocin release?)

21
What are non-pharmacological options for
treatment of postpartum depression?
  • Cognitive Behavioral Therapy
  • Good results w/ group approach
  • 10-40 fail to complete full treatment (similar
    to pharmacotherapy)
  • May have enduring effects not seen w/
    pharmacotherapy (up to two years)
  • Six sessions of non-directive counseling w/ child
    health nurses was more effective than routine
    primary care in Sweden
  • Telephone-based peer support out-performed care
    as usual (five 30-minute conversations)

22
Back to your patient
  • You see Josie frequently in clinic in the early
    postpartum period (newborn checkups and her own
    visit)
  • At two weeks postpartum
  • She describes low energy, worrying that she is
    not a good mom, difficulty sleeping, prolonged
    episodes of crying
  • Denies SI/HI, hallucinations, etc.
  • Is able to care for her baby but not enjoying it
    much
  • You review options for treatment of postpartum
    depression, including risks of no treatment
  • She elects to start medication
  • Used sertraline with good effect previously, so
    you rx 50mg daily
  • You see her in f/u in 2 weeks
  • Feeling better, no mania, bonding with baby, but
    some sxs persist
  • You increase sertraline to 100mg daily and
    schedule her back in 2 weeks

23
How can her partner and family members help?
  • Mothers without social support twice as likely to
    develop postpartum depression
  • Among Latina women, those satisfied with
    marital/partner relationships showed lower risk
    of depressive sxs postpartum
  • Among high risk women, better social support ?
    quicker improvement in depressive sxs
  • Educate partner about signs of mania/hypomania
    can be uncovered w/ use of SSRI. Also educate
    about the importance of treatment!

24
Evaluation and Treatment of Postpartum
Thromboembolic Disease
25
How do patients with thromboembolic disease
present in the postpartum period?
  • Silvia is a 37 y/o G5P5 at 9 days s/p repeat c/s
    performed at 37 wks for pre-eclampsia
  • She has a BMI of 43
  • She presents w/ increasing left leg pain and
    swelling for 2 days
  • On exam, you note the left calf is 4cm larger in
    circumference than the right and is tender to
    palpation and slightly erythematous
  • She has no dyspnea, tachypnea, or hypoxia

26
What are the risk factors for thromboembolic
disease in the postpartum period?
  • Age gt 35
  • BMI gt 30
  • Grand multiparity
  • Fam hx of VTE/thrombophilia
  • Bed rest
  • Immobility for gt 4 days
  • Pre-eclampsia
  • Severe varicose veins
  • Cesarean delivery (OR 13.3, 95 CI 3.4-51.4)

Virtualmedicalcentre.com
27
What is the incidence of VTE in postpartum women?
  • 0.5-3.0 per 1000 pregnancies
  • Equal incidence in each trimester and postpartum
  • 90 of DVTs in pregnancy are in the left leg
  • PE is more frequent in the postpartum period than
    during pregnancy (RR 15.0, 95 CI 5.1-43.9)

28
How is VTE diagnosed in the postpartum period?
  • Venous compression ultrasonography is the
    preferred test for dx of DVT
  • 89-96 sensitive and 94-99 specific for
    symptomatic proximal LE DVT in non-pregnant
    patients
  • Current spiral CT technology is comparable to
    pulmonary angiography in positive and negative
    predictive values for PE
  • CT delivers more radiation to the breast than V/Q
    scan, which may be preferred in those w/ family
    hx of breast cancer

29
How is VTE treated in the postpartum period?
  • Warfarin can be started at the same time as low
    molecular weight heparin or unfractionated
    heparin
  • LMWH (1 mg/kg SC bid) or UFH (80 units/kg loading
    dose iv, then continuous iv infusion of 18
    units/hour, or 17,500 units SC q12h)
  • aPTT goal is 1.5-2.0 X upper limits of normal
  • Continue LMWH or UFH until INR is 2.0-3.0 for 2
    consecutive days
  • Treat until 3-6 months post-diagnosis and for at
    least 6 weeks postpartum

30
Back to your patient
  • Her risk factors are age, c/s, pre-e, obesity
  • Her LE doppler confirms left DVT
  • She is appropriate for outpatient treatment
  • Given LMWH 100mg SC in OBT
  • Rx for bid LMWH is phoned to her pharmacy and
    emergency prior authorization is approved
  • She also starts warfarin and is given a f/u appt
    in the Coumadin Clinic
  • Is that okay for breastfeeding moms??Yes
  • Should she be given prophylaxis in a subsequent
    pregnancy?
  • Yes She falls under the criteria of no known
    thrombophilia with previous single episode of VTE
    associated with transient risk factor that was
    pregnancy- or estrogen-related.

31
Endomyometritis, C-section Wound Infections, and
Perineal Wound Complications
32
A postpartum woman with fever
  • Delia is a 32 y/o G1P1, 7 days s/p c/s for
    failure to progress following induction for GDMA2
  • Complains of onset of fever and chills yesterday
    evening, resolved w/ ibuprofen overnight,
    recurrent this morning with temp 102 at home
  • Reports her VB has increased slightly in the last
    24h, notes a foul vaginal odor and some vague
    abdominal pain

33
How does postpartum endomyometritis present and
what are the pathogens involved?
  • Temp gt 38.0 (100.4), chills
  • Uterine tenderness
  • Foul lochia
  • Lower abdominal pain
  • Fundus soft instead of firm, sub-involuted (above
    umbilicus, excessive VB)
  • Microbiology
  • Usually mixture of 2-3 aerobes and anaerobes,
    including gram pos and neg rarely GC/CT
  • Rare but potentially lethal bacteria clostridium
    sordellii, clostridium perfringens, strep or
    staph toxic shock

34
What are risk factors for postpartum
endomyometritis?
  • C/s most important
  • Prolonged labor or ROM
  • Lots of cervical exams
  • Internal monitors in labor
  • Manual placenta extraction
  • Maternal DM or severe anemia
  • BV or GBS colonization

35
How is postpartum endomyometritis evaluated and
diagnosed?
  • Physical exam
  • Fever, tachycardia
  • Uterine tenderness on abdominal or bimanual exam
  • Look for findings associated with other causes of
    fever, such as surgical site infection, pelvic
    abscess, mastitis, UTI/pyelo, DVT/PE
  • Rising neutrophil count w/ increased bands (WBCs
    commonly elevated in labor, but should not
    continue to rise postpartum)
  • Blood cx
  • GC/CT if not done prior, positive earlier in
    pregnancy, or patient at increased risk
  • Imaging usually not indicated unless fever is
    persistent after 48-72h of abx or VB is heavy
    (fluid/debris/gas in uterus can be normal)

36
How is postpartum endomyometritis treated?
  • Clindamycin 900mg iv q8h plus gentamicin 5mg/kg
    q24h (or 1.5mg/kg iv q8h), w/ 90-97 cure rate
  • Treat until clinically improved and afebrile X
    24-48h further oral tx not required unless
    bacteremia present based on positive blood cx
  • If fever persistent, add ampicillin, vs. change
    to ampicillin/sulbactam (Unasyn)1.5g iv q6h,
    which can also be used first-line
  • Uterine suction currettage occasionally required
    to remove POCs shown on U/S (if not improving or
    bleeding heavy)
  • In late postpartum endomyometritis (1-6 weeks
    postpartum and usually milder sxs, 15 of all
    disease), amoxicillin-clavulanate 875mg po bid X
    7 days is acceptable

37
What if your patient presented with no fever, but
increased pain at her c/s incision site?
  • Risk factors for c/s wound infection similar to
    endomyometritis
  • Wound appears erythematous and induration can be
    palpated
  • Evaluate for seroma, hematoma, or abscess,
    including probing down to the fascia w/ a sterile
    cotton-tipped applicator if the wound opens
  • Wound aspirate (rather than swab) for cx
  • After drainage of an abcess/opening the wound,
    irrigate and pack w/ sterile gauze, w/ healing by
    secondary intention
  • Antibiotics
  • Cephalexin 500mg po qid X 7 days
  • Clindamycin if MRSA suspected
  • Both are fine for breastfeeding
  • Close follow up is important

amamasblog.com
38
How do postpartum patients with perineal
laceration complications present?
  • Tanya is a 20 y/o G1P1 s/p vacuum-assisted
    vaginal delivery for failure to descend and fetal
    intolerance of labor
  • She had a second degree perineal laceration
    repaired
  • She presents 3 days postpartum with perineal pain
  • She reports a subjective fever at home, but is
    afebrile in your office, with no recent
    antipyretic use
  • On perineal exam, no erythema, sutures appear
    intact, no foul-smelling discharge, external anal
    sphincter and rectovaginal septum intact, but a
    hematoma is noted of the left labia

39
What is the differential diagnosis and treatment
for perineal pain postpartum?
  • Labial/vaginal hematoma incise, evacuate, and
    ligate the bleeding vessel(s) if continues to
    expand or appears infected if stable and not
    large, may resorb spontaneously

Williams Obstetrics, 23 Ed.
40
What is the differential diagnosis and treatment
for perineal pain postpartum?
  • Perineal infection
  • Open any organized abscess (imaging may be
    required to assess for tracking of the abscess
    into deep tissues)
  • Consider removing suture material
  • Verify that a third or fourth degree laceration
    has not been overlooked
  • Antibiotics (may require admission)
  • Look for hemorrhoids and anal fissures, treat
    accordingly
  • Discuss in private whether pressured/forced to
    have sex before completely healed

41
Back to your patient
  • Delia has endomyometritis by hx and exam
  • Admitted for iv gent and clinda
  • Becomes afebrile after 18 hours of abx
  • Txd until afebrile for 24h and no fundal
    tenderness, then abx d/cd and observed for 24h
    off abx, remained afebrile
  • Tanya has a 3 X 3 cm labial hematoma
  • She states that lump has been there since a few
    hours after the delivery and its the same size
    as yesterday
  • Vitals are normal
  • There is no surrounding erythema or induration
  • You elect conservative management, give
    precautions, and bring her back in 48h for
    re-examination

42
Management of Breastfeeding Difficulties
43
What types of breastfeeding difficulties do women
encounter postpartum?
  • Cassandra is a 28 y/o G1P1, 10 days s/p term NSVD
  • Exclusively breastfeeding, 3 days of breast pain
  • Nipple pain starts at latch and lasts entire
    feeding, plus shooting pains that radiate from
    nipple back into breast occurring w/ letdown and
    feeding
  • No fevers, chills, or body aches
  • Nipples and areolae are bright pink cracks and
    fissures on both nipples no other erythema,
    warmth, induration or fluctuance
  • Baby appears to have oral thrush

44
How is breast candidiasis evaluated?
  • Pain from intraductal yeast infections is often
    described as shooting and radiates from nipple to
    chest wall, and is out of proportion to the
    clinical exam
  • Nipple/areola may appear shiny or flaky
  • Skin scraping for microscopy
  • Positive breast milk culture
  • Often associated w/ other yeast infections in the
    infant, such as thrush or diaper area dermatitis
  • There is not universal agreement among clinicians
    and researchers regarding the existence of this
    clinical entity

45
How is breast candidiasis treated?
Blisstree.com
  • Infant and mother treated
  • Topical nystatin or gentian violet for infant
  • Topical nystatin, miconazole, or ketoconazole for
    mother if infection seems to be cutaneous only
    (not intraductal)
  • Another option is oral fluconazole (Diflucan) for
    mom, /- baby (not FDA approved, but used
    frequently for moms)
  • Mother 400mg po on day one, then 200mg po daily
    X at least 10 days
  • Infant 6-12mg/kg po on day one, then 3-6mg/kg
    po daily X at least 10 days

46
What are the risk factors for mastitis?
  • Most common in 2nd and 3rd weeks postpartum
    (75-95 occurring before infant is 3 mos of age)
  • Poor breastfeeding technique
  • Infant cleft lip/palate or short frenulum
  • Cracked nipples
  • Missed feeding(s)
  • Nipple piercing
  • Poor maternal nutrition
  • Plastic-backed breast pads, tight bra
  • Yeast infection
  • Manual pump use

Breastfeedingbasics.com
47
What interventions can decrease the risk of
mastitis?
  • Improve breastfeeding technique and latch
  • Apply expressed breast milk or lanolin to nipples
    and areolae
  • Treat yeast infections
  • Consider frenotomy

48
How is mastitis diagnosed and treated?
  • Localized, unilateral breast tenderness and
    erythema
  • Fever, malaise, fatigue, body aches, headache
  • Breast milk cultures rarely indicated, unless
    infection fails to respond to tx
  • Most common organism is S. aureus
  • Treat with antibiotics and improving
    breastfeeding technique
  • Complete emptying of the breast is key, and
    breastfeeding should continue this decreases
    risk of abscess

49
How is mastitis diagnosed and treated?
  • Antibiotic choices
  • Amox/clav 875 mg po bid
  • Cephalexin 500 mg po qid
  • Clindamycin 300 mg po qid
  • Dicloxacillin 500 mg po qid
  • TMP/SMX 160/800 mg po bid (avoid in mothers of
    infants lt 2mos or sick infants of any age)
  • Duration of tx usually 10-14 days
  • Abscess should undergo ID or needle aspiration,
    w/ fluid sent for culture, and breastfeeding can
    usually continue

50
Another patient with breastfeeding difficulties
  • Noemi is a 24 y/o G2P2 s/p NSVD at 36 weeks
    following spontaneous preterm labor
  • Mother and infant discharged home at 2 days
    postpartum, w/ LATCH score of 7-8
  • Followed closely in clinic for infant weight gain
  • Infant is now 6 weeks old, and mom returned to
    work 2 weeks ago
  • Having a hard time pumping at work, and thinks
    milk supply is decreasing
  • Babys grandma has been giving an ounce or two of
    formula, along w/ EMB, while mom at work

51
Why should we promote exclusive breastfeeding?
  • Human milk provides
  • Nutrients and energy for rapid growth and
    development
  • Protective factors against infection
  • Otitis media, diarrheal illness, upper
    respiratory infection
  • Decreases pain and suffering
  • Reduces lost work time for parents
  • Chronic disease prevention
  • Diabetes mellitus
  • Celiac disease
  • Childhood cancers
  • Atopic disease
  • Multiple sclerosis
  • Inflammatory bowel disease

52
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53
What are the costs of suboptimal breastfeeding in
the U.S.?
  • 2010 study by Bartlick and Reinhold, published in
    the journal Pediatrics
  • Looked only at costs of pediatric diseases
  • Used 2007 dollars
  • If 90 of US families breastfed exclusively for 6
    months, the U.S. would save 13 billion and
    prevent 911 deaths
  • At 80 compliance, savings would be 10.5 billion
    and 741 deaths

54
What are current breastfeeding recommendations?
  • American Academy of Pediatrics and American
    Academy of Family Physicians
  • 4-6 months exclusively
  • Continue for at least 1 year
  • World Health Organization
  • 4-6 months exclusively
  • Continue for at least two years

55
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56
How can we help women maintain/increase breast
milk production?
  • Avoid introduction of formula
  • Pump q 3h when away from baby
  • Pump immediately after each feed
  • Adequate rest, nutrition, and hydration for
    mother
  • Have a nurse-in
  • Natural products mothers milk tea, oatmeal,
    etc.
  • Metoclopromide course for mom 10 mg po tid X 10
    days (or other regimens/drugs)
  • Advocate for breastfeeding-friendly policies in
    your own workplace and community!

57
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58
Evaluation and Management of Newborn Jaundice
59
A newborn at risk for hyperbilirubinemia
  • Baby Girl T was delivered to a 40 y/o G1P0 at 35
    6/7 wks GA via emergent c/s for fetal bradycardia
    occurring following combined spinal-epidural for
    planned external cephalic version in setting of
    PPROM and breech
  • DOB 5-13-15 at 0550, Apgars 3 9, LD BW 2260g
  • PPV at delivery, MBU for couplet care, MBU BW
    2240g
  • Initial bili 7.2 at 28 hours of life
  • Coombs negative
  • Exclusively breastfed
  • D/cd home day 3, f/u day 5 with bili of 20.3, wt
    2120g

60
How is newborn jaundice evaluated in the
outpatient setting?
  • Is breast milk intake adequate?
  • Insufficient intake?decreased stool
    production?increased reabsorption of bili from
    gut?elevated unconjugated (indirect) bili
  • Weight loss or insufficient gain?
  • Poor urine or stool output? Persistent meconium
    stools?
  • Elevated bili?lethargy and poor feeding?higher
    bili
  • Inadequate intake?dehydration, malnutrition, risk
    of kernicterus
  • Often called breastfeeding jaundice but should
    be called not-enough-breastfeeding jaundice

61
How is newborn jaundice evaluated in the
outpatient setting?
  • Are there risk factors for hemolysis?
  • Polycythemia
  • Cephalohematoma or bruising at birth
  • ABO incompatibility or Rh isoimmunization
  • Red cell glucose metabolism enzyme deficiencies
    pyruvate kinase
  • Hereditary spherocytosis or other RBC membrane
    abnormalities

62
Could it be breast milk jaundice? What is that?
  • Presents in the first or second week of life
  • Can persist for up to 12 weeks
  • Resolves spontaneously
  • Incidence 36 in exclusively breastfed infants
  • Hypothesized to involve a breast milk component
    that increases enterohepatic circulation of
    bilirubin
  • Weight gain, stool/urine output, and physical
    exam should all be normal
  • Total serum bili in breast milk jaundice alone
    should be lt 12 mg/dl
  • Conjugated (direct) bili should be less than
    1mg/dl

63
How can you be sure its just breast milk
jaundice?
  • If direct bili lt1 but total bili is gt12,
    additional evaluation is needed
  • First r/o hemolysis hct or hgb, reticulocyte
    count, coombs, peripheral smear
  • Test for G6PD deficiency
  • People of African, Asian, Latino, Mediterranean
    and Middle Eastern descent at higher risk
  • 4.9 of worlds population affected 12 of
    African American men, 4.3 of Asian American men
  • X-linked, but can also affect females
  • Risk of false negative test from larger amount of
    G6PD in young RBCs, more released w/
    hemolysisconsider retesting when jaundice is
    resolved
  • Review newborn metabolic screen results
  • Consider parental bili levels for Gilberts
  • Testing for all UGT 1A1 mutations is not readily
    available, but some are obtained w/ newborn
    metabolic screening

64
What does UGT 1A1 do and what are the associated
mutations?
  • UGT 1A1 (uridine diphosphate glucuronosyltransfera
    se 1A1) hepatic enzyme that conjugates
    bilirubin
  • After conjugation, bili travels to small
    intestine in bile
  • Intestinal flora converts it to stercobilin
  • Stercobilin is excreted in stool
  • Beta-glucuronidase can deconjugate bili
  • Deconjugated bili is absorbed by intestinal
    mucosa and returned to liver via portal
    circulation (enterohepatic circulation)
  • UGT 1A1 mutations
  • Crigler-Najjar type I 1 in 1 million babies, no
    enzyme production, critically high bili,
    kernicterus and death if untxd in newborn
    period, most die later in life of kernicterus
    liver transplant is currative
  • Crigler-Najjar type II indolent course,
    elevated bili but below LL, responds to phenobarb
    which induces UGT 1A1 production
  • Gilberts syndrome 8 prevalence, eznyme
    levels 1/3rd to 1/10th of normal, mild effect on
    bili but could be additive w/ another cause

65
What are some other non-hemolytic etiologies?
  • Biliary atresia
  • Neonatal hepatitis
  • Galactosemia
  • Hypothyroidism
  • Pyloric stenosis
  • Annular pancreas
  • Duodenal or jejunal atresia
  • Sepsis
  • Medication exposures ceftriaxone,
    dicloxicillin, sulphonamides

66
Our patients clinical course
Date Time Bili Tx Level Weight Action
5/14 0945 7.2 10.5 Observe
5/15 0700 10.0 13.2 Observe
5/16 0600 13.8 15.5 2100 D/c home
5/18 0845 20.3 18 2120 Admit for photo tx
5/18 2100 15.0 18 Continue photo tx
5/19 0830 10.7 18 2150 D/c photo tx and d/c home
5/22 1045 14.1 F/u in 6d
5/28 0915 18.0 (dir0.4) 2330 MCH consulted, feed freqly, f/u for wt
6/1 1545 17.8 (dir0.4) 2410 F/u 4-7d
6/8 0930 19.7 (dir0.6) 2330 Wt loss noted, MCH consulted w/ plan to admit, PCP rec no admit, supplement w/ formula, G6PD, retic, repeat coombs.
6/9 1515 16.2 (dir0.5) 2380 On-call resident leaves vm for mom to go to Peds ED. Email communication b/w mom and PCP that Peds ED not needed.
6/10 2450 Got 30cc formula after each breast feed.
6/11 1145 12.7 (dir0.4) Mom notified by PCP, continuing care at Pres per prior plan.
67
Phototherapy Guidelines
68
Newborn Jaundice Clinical Decision Making Pathway
Preer GL, Philipp BL. Understanding and managing
breast milk jaundice. Arch Dis Child Fetal
Neonatal Ed (2010). doi10.1136/adc.2010.184416
69
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