Anemia of Prematurity - Portal Neonatal

History:
CLINICAL Section 3 of 9
• Physiologic jaundice usually manifests in the first 2-4 days of life. This can be accentuated
by breastfeeding, which in the first few days of life results in lower calorie intake,
especially if milk production starts late. This is known as breastfeeding jaundice. Jaundice
that manifests before the first 24 hours of life should be considered pathologic until proven
otherwise. In this situation, a full diagnostic workup focusing on evaluation of sepsis and
hemolysis should be undertaken.
• True breast milk jaundice manifests during the first 4-7 days of life. A second peak in
bilirubin level is noted at approximately the 14th day of life.
• In clinical practice, differentiating between physiologic jaundice from breast milk jaundice
is important so that the duration of hyperbilirubinemia can be predicted. Identifying the
infants who become dehydrated secondary to inadequate breastfeeding is also important.
These babies need to be identified early and given breastfeeding support and formula
supplementation as necessary. Depending on serum bilirubin concentration, neonates
with hyperbilirubinemia may become sleepy and feed poorly.
Physical:
• Clinical jaundice is usually first noticed in the sclera and the face. Then it progresses
caudad to reach the abdomen and below. Gentle pressure on the skin helps to reveal the
extent of jaundice, especially in darker-skinned babies; however, clinical observation is
not an accurate measure of the severity of the hyperbilirubinemia.
• A rough correlation between blood levels and the extent of jaundice (face, approximately
5 mg/dL; mid abdomen, approximately 15 mg/dL; soles, 20 mg/dL) exists. Therefore,
clinical decisions should be based on serum levels of bilirubin. Skin should have normal
perfusion and turgor and show no petechiae.
• Neurologic examination, including neonatal reflexes, should be normal, although the infant
may be sleepy. Muscle tone and reflexes (eg, Moro reflex, grasp, rooting) should be
normal.
• Evaluate hydration status by an assessment of the percentage of birth weight that may
have been lost, observation of mucous membranes, fontanelle, and skin turgor.
Causes:
• Supplementation of breastfeeding with dextrose 5% in water (D5W) actually can increase
the prevalence or degree of jaundice.
• Late milk production and poor feeding lead to decreased caloric intake, dehydration, and
increased enterohepatic circulation, resulting in higher serum bilirubin concentration.
• The biochemical cause of breast milk jaundice remains under investigation. Some
research reported that lipoprotein lipase, found in some breast milk, produces
nonesterified long-chain fatty acids, which competitively inhibit glucuronyl transferase
conjugating activity.
• Glucuronidase has also been found in some breast milk, which results in jaundice.