Newborn Jaundice for Nurse Practitioners
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Show notes:
For newborn babies with jaundice, still, after 5 years, I run my plan of care by one of my family medicine or pediatric colleagues.
And to be honest, for good reason -- what we’re talking about is the difference between needing to go back to the hospital for phototherapy or not.
Assessing Newborn Jaundice
In this week's video, I’m doing the 30,000 foot view of jaundice in late-preterm and term infants in the primary care setting to help you understand how all the pieces fit together, the most important things you need to know, and my favorite tool to use to help with decision making.
Disclaimer though: like I said, I still run my plan of care by someone every time, so depending on your comfort level, tread very cautiously with these little ones.
Resources mentioned in this episode:
If you liked this post, also check out:
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well hey there it's liz rohr from real
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world np and you're watching np practice
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made simple the weekly videos to help
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save you time
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frustration and help you learn faster so
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you can take the best care of your
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patients
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so this week i'm talking about newborn
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jaundice and full disclosure these
NEWBORN JAUNDICE
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visits still make me a little bit
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nervous
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so if after five years of practice so if
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they make you nervous that's
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it's totally normal so i'm going to in
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this video i'm going to give like a
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broad overview like a 50 000 foot view
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of like the general thing that i see in
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primary care in family medicine
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and so the context is it's usually a
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three or four day old baby
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who's coming in for their initial check
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and then they have some sort of history
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of jaundice or it's a newer onset
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jaundice and it's usually
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in this video i'm talking about a 35
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weekend up gestational age born
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baby so late pre-term or term infant um
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and i'm also going to be talking about
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like kind of like what to be assessing
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when to consider the other potential
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differential diagnoses like what we're
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actually looking at here
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and then like the tools and resources
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that i use to make those decisions going
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forward of
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in terms of the management and the
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follow-up and all that stuff so
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um benign neonatal hype unconjugated
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hyperbilirubinemia
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neonatal jaundice isn't expected finding
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so i just want to it's an expected
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finding with some caveats so just
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pausing here for a second so i want to
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talk about bilirubin metabolism
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uh i am a super nerd and i love this
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stuff but i'll try to make it real
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simple basically and this may be a
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refresher for you anyway right
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so hemoglobin is broken down heme is
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broken down into bilirubin
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generally speaking very broad overview
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um it's brought into the serum with
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albumin
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conjugated no sorry unconjugated
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i always get them confused because the
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terminology is confusing so unconjugated
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and indirect in the serum goes over to
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the liver
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the liver breaks off that albumin it's
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conjugated or direct
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right because it's directly just the
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bilirubin now and there's nothing
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attached to it
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and then it's that's like the processing
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and then it's excreted into the urine in
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the stool
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and so for babies for newborn babies
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for the most part they are have fetal
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hemoglobin breakdown
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and they have immature livers right so
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that's just it's just overwhelming the
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system
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um and so that brings to two two
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different things one the main reason we
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care about it
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is because too much bilirubin gets
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across that blood-brain barrier and can
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cut and can cause
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neurotox toxicity and so what we're
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trying to assess is like number one is
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this expected unexpected finding
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how severe is it are they at risk for
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that neurotoxicity
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and can they take care of it on their
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own can their body take care of it or do
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they need additional assistance
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so the main treatments which brings me
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to the main treatments depending on the
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underlying factors
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which i'll get to in a second is uh
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po intake breast milk formula eating
PO INTAKE
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stooling urinating getting rid of it um
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and uh the other one is phototherapy um
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so a couple of other
PHOTOTHERAPY
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and i'll just pause there for a second a
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couple other things i want to say first
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before we kind of get into the
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assessment
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stuff is that there is an expected
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peak it's kind of like a it kind of goes
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on this like mountainous
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little little peak and then back down
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again and there's an expected peak
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post post birth um in again term
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late preterm and term infants that's
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about 48 hours
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to 120 hours where that's the expected
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peak there's this little drawing right
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and so when we're when we're
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interpreting the bilirubin results
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in the context of their physical
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symptoms we're comparing it to those
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expected findings based on their
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time of birth and how many hours old
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they are if that makes sense right so
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it's not just days it's hours how many
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hours from birth are we
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and what is that billy ribbon um level
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so
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that's a lot of information but
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basically that's the that's the
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background
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right and so when you the context here
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is that it's a newborn baby that's about
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three or four days old who has some
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jaundice
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your job is the primary care is to just
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kind of
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orient yourself like where are we in
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this so uh jaundice tends to um present
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itself in a cephalocaudal pattern and so
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you want to see like how severe the
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jaundice is on physical assessment is
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the sclera involvement is it down to the
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chest down to the navel
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that whole thing and you also want to do
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your general assessment
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right that you're doing as a newborn
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visit um which i talked about in the
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last week's video if you haven't watched
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that already go back and do that
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but basically what we're talking about
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is like how are they eating
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right because again the treatment here
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is like
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po intake for the most part right this
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is not 100 right
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but like for the most part there's po
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intake and that's going to help clear it
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on their own
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um how are they eliminating do they have
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have they passed meconium already
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what kind of stool do they have what
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does it look like are they urinating
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adequately how many diapers per day
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which again i talk about in that video
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how often are they feeding are they
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breast milk only formula
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as well only formula like that is that
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is important to know as well
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and like how often how long like all
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that stuff and like i said i can i'm
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happy to bring on my
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uh colleague who is a lactation
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consultant and i checked with her and
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she is interested maybe audio and not
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video we'll see
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um if you have questions about that but
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um
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but yeah so you're basically like
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assessing uh
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what what their appearance is
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cognitively like right like
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neurotoxicity risk factors are they
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lethargic are they
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um normal like alertness again difficult
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to assess in newborn babies but always
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check if you need any any help with any
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of your colleagues right
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and then talking about their elimination
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and then the next kind of important
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thing to think about
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is like what are the risk factors um and
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then how are you gonna differentiate
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between
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um physiologic expected jaundice and
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pathologic so
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couple of thoughts about that so the
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differential diagnosis for
DIFFERENTIAL DIAGNOSIS FOR PATHOLOGIC JAUNDICE
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pathologic jaundice for
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hyperbilirubinemia
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is really long so please consult your
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resources and just take a peek at that
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to kind of familiarize yourself with the
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potential differentials
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the main factors that will trigger you
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to think that it is more of a pathologic
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jaundice versus a physiologic jaundice
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is typically when it appears within the
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first 24 hours after birth
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there's like a rapidly rising level
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that's more than about
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5 milligrams per deciliter per day i'm
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looking at my notes over here
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and then having a total serum bilirubin
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higher than 17
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milligrams per deciliter in a full full
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term
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newborn those are potential kind of like
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flags to think about those other options
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also if there's anything abnormal in
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your physical assessment or how they're
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doing
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um i i will ask right because for the
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most part when i see babies who are like
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this
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everything is expected findings right
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and they're eating adequately they're
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stealing adequately
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they have no other symptoms and no
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neurologic symptoms like anything like
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that
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um but i again i always ask if i need
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help so a couple of thoughts um
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just to share about breastfeeding versus
BREAST FEEDING VS FORMULA FEEDING
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formula feeding so you actually may see
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an exaggerated jaundice
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response for babies who are
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are exclusively breastfed because of the
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relative caloric
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intake is slightly less as compared to
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formula because it's colostrum and
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waiting until the um the milk production
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is coming in
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it doesn't necessarily mean that it's
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dangerous it's just something to to keep
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into consideration
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the main thing that i find again the
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most common thing in primary care and
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family medicine
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is like making sure if they're not
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formula feeding
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uh to make sure that their latch is
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adequate and that they're eating enough
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they're
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they're taking in enough because that's
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the cases that i've seen is that they're
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they're breastfeeding and they're sort
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of doing well but then they have some
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trouble
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in a couple of days and then the
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jaundice gets worse and
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all that stuff one other fun fact that i
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found is that the total serum bilirubin
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level and i can link to this article
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down below
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can be estimated clinically by the
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degree of caudal
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extension so the face is 5 upper chest
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is 10
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abdomen is 12 and then palms and souls
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are is greater than 15. that is so
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interesting i don't actually know the
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stats on that but it's a
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reputable resource so lastly i just
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wanted to share the tool that i use and
TOOLS THAT I USE
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so
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when i have babies who are like this i'm
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doing my full assessment
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with that kind of background information
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in mind and i'm looking at their birth
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history i'm looking at their gestational
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age
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i'm looking at the notes that they had
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in the discharge summary that will kind
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of clue you into
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earlier onset jaundice what were their
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bilirubin levels then
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like that kind of thing and then i'm
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going and using the ability so the
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is the website that i use and i have no
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affiliation with them it's just the one
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that i use and my whole clinic uses
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actually
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and basically what you do is you plug in
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the
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date of birth and the time of birth then
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you plug in the um
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the the the time of the sample like
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serum lab draw
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as well as that bilirubin level and it
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will spit out to you basically like
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um what the risk fact what the risk
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level is
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and you need to interpret that in
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accordance with again your findings in
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front of you but additionally
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what are your other things to think
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about and so it will it will category to
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categorize it as low medium or high risk
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and that is further categorized by
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their potential risk factors as well as
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how old they are
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um in terms of gestational age at birth
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and so i'm looking over at my notes here
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but
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uh just so i don't like misspeak it's a
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free tool so i definitely recommend
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using it and i just
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have to say again full disclosure
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whenever i fill this out
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i'm just running my plan by somebody
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because i want to make sure that i'm not
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like making a mistake or you know
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misunderstanding the interpretation
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because it's a little bit it's a little
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bit involved but it is really really
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helpful
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um but yeah so some of the
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hyperbilinemia risk
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factors that would potentially increase
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their risk of a higher bilirubin level
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faster again
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the main thing we're thinking about is
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neurotoxicity so if it gets too high we
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need to bring it back down either with
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phototherapy
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or usually with phototherapy if it's
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getting too high you need to do some
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sort of intervention you can't just
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leave it on its own but the risk factors
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to think about
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is if it's in a high risk zone like how
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high the bilirubin level is compared to
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their
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date and time of birth how many hours
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old they are
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if they had jaundice in the first 24
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hours again if they had that i'm
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consulting with somebody
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um any incompatibility would would
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likely be already addressed on your
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discharge summary paperwork but again
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i'm going to consult with somebody for
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that
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gestational age 35 to 36 weeks you
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definitely want to be careful with that
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they have again more
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immature livers if they had a sibling
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with prior phototherapy
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any cephalo hematoma or bruising and
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then again just keeping in mind with
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exclusive breastfeeding it's not
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necessarily
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it's not a harmful thing of course but
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it potentially increases uh it adds a
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risk factor especially if they're not
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latching well if they're not feeding
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well if they have significant weight
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gain weight
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loss excuse me um east asian race is
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potentially a risk factor but again
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race is a social construct and it's a
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poor proxy for biological risk factors
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um so loosely keeping that with a grain
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of salt
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and then there are other some
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neurotoxicity risk factors which are a
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little bit
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like way less common and a little bit to
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get into on this video
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but again just consulting with your
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resources so i'll link to both those
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resources um that article and
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billytool.org down below this video but
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hopefully this video was helpful
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um if you have any questions please
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leave them for me below if you'd like to
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hear from my lactation consultant
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physician friend please let me know
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i will reach out to her and um if you
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in there and i'll see you soon
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[Music]
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you
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