Anemia of Prematurity - Portal Neonatal

milk intake because of reduced mammary gland milk production in the first few
days postpartum. Breastfeeding jaundice should be distinguished from breast milk
jaundice.
� Some breastfed infants, while clinically thriving, continue to manifest an indirect
hyperbilirubinemia of unidentifiable etiology for several months. If this is witnessed
in a breastfed infant, the exclusion diagnosis of breast milk jaundice may be made.
Such hyperbilirubinemia is thought to be caused by persistently high levels of asyet-unidentified
components in some women's breast milk, which result in
persistence of the infant's hyperbilirubinemia. One clue may be a history of similar
hyperbilirubinemia in other breastfed siblings. This entity is benign.
DIFFERENTIALS Section 4 of 11
Fetal Alcohol Syndrome Head Trauma
Hearing Impairment Herpes Simplex Virus Infection
Hyperammonemia Hypothyroidism
Meningitis, Bacterial Neonatal Sepsis
Periventricular Leukomalacia
Other Problems to be Considered:
Cerebral palsy Hypoxic-ischemic brain injury in the newborn
Sepsis
Lab Studies:
WORKUP Section 5 of 11
• Hematologic studies: Hematologic laboratory evaluation is the cornerstone of evaluation of the
baby with hyperbilirubinemia. Although jaundice can be appreciated clinically, observation
alone is not a reliable method to assess the severity or estimate risk factors for the infant.
• Total and direct bilirubin: Quantitative measurement of total and direct bilirubin should be
undertaken in every baby at risk for significant hyperbilirubinemia or kernicterus. Total bilirubin
measures the aggregate of all forms of bilirubin in the serum. The direct fraction measures the
amount of conjugated bilirubin. Subtraction of the direct fraction from the total yields the
calculated indirect bilirubin, or the unconjugated form. Remember that the indirect fraction is
composed of bound bilirubin, free bilirubin, and lumirubin if the baby is under phototherapy.
Only the free bilirubin is available to cross the blood-brain barrier and has the potential to
cause neurotoxicity. Attempts to measure the amount of bound albumin or to estimate the
bound fraction from measures of serum albumin have not proved to be clinically useful.
o Serial measurements may be necessary to track the evolution of hyperbilirubinemia;
frequency of measurements depends on the baby's gestational age, chronologic age,
risk factors, and other clinical characteristics.
o Every baby with hyperbilirubinemia should have a direct fraction measured at least
once to rule out direct hyperbilirubinemia. Direct hyperbilirubinemia in the neonate is
defined as a direct fraction greater than one third of total bilirubin and is always
pathologic. Subsequently, if the hyperbilirubinemia is established as the indirect type,
obtaining a direct fraction with every measurement is unnecessary unless the
hyperbilirubinemia develops after the expected time frame for typical neonatal
hyperbilirubinemia.
o With the advent of early discharge (before the physiologic peak of serum bilirubin)
some clinicians are advocating universal bilirubin measurements in all babies prior to
discharge. Nomograms have been published that estimate a baby's risk of disease
based on measured levels of bilirubin. The most recently published nomogram uses
an hour-specific approach to address the difficulties posed by babies leaving the
hospital within 24-48 hours of birth (see Image 3).