Hyperbilirubinemia in out-patient conditions.

[Soto]

It would be desirable to lift this subject in discussion for the several reasons:

1 - its or her importance is caused by high frequency of hyperbilirubinemias of newborns (I judge or I shall narrow across Ekaterinburg, on job of specialized out-patient city sectioning)

2 - not otrabotannost at an out-patient stage dif.diagnostiki hyperbilirubinemias. What can the local pediatrist really make? What criteria to hospitalization? At times and with digits of one only a bilirubin in 100 mkmol *quot; O?anUoa?O?n*quot;, but it is not rare and with digits 150-180, with cytolysis till 2 months the child remains on a site.

3 - approaches to therapy at an out-patient stage. Now that only it is not appointed or nominated - every possible sorbents (smekta, filtrum and other), gepatoprotektory (-52, Essentiale, geptral), other preparations (Fenobarbitalum, cholagogue and so forth). Whether really organization of phototherapy domiciliary?

[dr. Ira]

It would be desirable to lift this subject in discussion for the several reasons:

1 - its or her importance is caused by high frequency of hyperbilirubinemias of newborns (I judge or I shall narrow across Ekaterinburg, on job of specialized out-patient city sectioning)

2 - not otrabotannost at an out-patient stage dif.diagnostiki hyperbilirubinemias. What can the local pediatrist really make? What criteria to hospitalization? At times and with digits of one only a bilirubin in 100 mkmol *quot; O?anUoa?O?n*quot;, but it is not rare and with digits 150-180, with cytolysis till 2 months the child remains on a site.

3 - approaches to therapy at an out-patient stage. Now that only it is not appointed or nominated - every possible sorbents (smekta, filtrum and other), gepatoprotektory (-52, Essentiale, geptral), other preparations (Fenobarbitalum, cholagogue and so forth). Whether really organization of phototherapy domiciliary?

Uv.kollega! I can will share only the Israeli report.

So, we speak about an indirect bilirubin and an icterus which has appeared not earlier, than for 3 day of a life, a level of a bilirubin no more 13/ on 4 (at us write out for 3 4 day), that the rhesus and the ao-CONFLICT is excluded in rod.dome. And the child gets to me (it is possible to tell or say *quot; to the divisional Nn?aOOO*quot;) I do or make repeatedly a bilirubin. If he falls, more I do not do or make NICHEGO.Esli was not present, depends... I begin inspection, including the formula +, monitoring of a bilirubin, +, a blood on TSH (accordingly d/n at an indirect hyperbilirubinemia) .esli all analyses *quot; OO?aON?y?U*quot;, the child does not have concealed hemorrhages (napr.kefalogematoma) it is a bilirubinemia connected with thoracal feeding. To do or make it is not necessary, certainly, TO CONTINUE TO FEED ANYTHING GRUDJU.ZHeltuha will pass or take place itself. The bilirubin thus NEVER raises or increases up to *quot; a??u*quot; a level.

If the reason for the prolonged bilirubinemia has come to light to treat it is necessary the reason. If an icterus physiological hospitalization depends on a level of a bilirubin in relation to day of a life (..16 on 5 day-hospitalization without fail, and on 7-monitoring and hospitalization only if continues to grow) the Basic treatment of a physiological icterus-phototherapy and only in hospital.

As to a direct bilirubin, /: (the earlier it is diagnosed, the better the forecast) an idiopathic neonatal hepatitis, an infection, including TORCH, a galactosemia, deficiency an alpha of 1 antitrypsin. Accordingly and inspection.

Yes, still there is deficiency G6PD, he too causes an indirect hyperbilirubinemia. As it is enough often widespread status at sefardskih Jews in Israel it is the routine analysis at inspection on the reasons of an indirect hyperbilirubinemia.

Well here, all seems. If something has forgotten, colleagues will add.

With .dr. Ira

[Melnichenko]

*quot; a blood on TSH (accordingly d/n) *quot;, an extract for 3-4 day. Ira, and unless there is no screening on congenital gipotiroz in Israel?

[dr. Ira]

*quot; a blood on TSH (accordingly d/n) *quot;, an extract for 3-4 day. Ira, and unless there is no screening on congenital gipotiroz in Israel?

Screening is. But the answer only in a month. And if from me the baby with an icterus the answer is necessary to me today (tomorrow) .poetomu and I take a blood.

With .dr. Ira

[Tanya G]

Ira, it turns out, and screening on VG does not work for you? I already framed a subject in this occasion... In that case, how to make so that money which are allocated zhdja revealings of a congenital hypothyrosis, were not spent all for nothing? And more - come into a subject in this occasion, express the opinion, pliz...

[Melnichenko]

We, certainly, suited a -topic with Tatyana Gennadevnoj, and Tatyana Gennadevny's offer to invite Irina to us in section on screening newborns fairly.

In Irina's support I shall notice, that Israel was left with only one clause or article (quoted in Pubmed) on screening (in 90th years), and more likely the fact of necessity of screening and clinic congenital gipotiroza, questions of optimization of terms of treatment there understood. The frequency specified in clause or article, most likely, zavyshennaja-in the beginning all found more, than really is present.

Am J Med Genet. 1992 Sep 1; 44 (1):57-60. Related Articles, Links





Congenital anomalies concomitant with persistent primary congenital hypothyroidism.



Siebner R, Merlob P, Kaiserman I, Sack J.



Department of Paediatrics, Sheba Medical Center, Tel-Hashomer, Israel.



The Israeli national neonatal screening program for congenital hypothyroidism (CH) was initiated in May 1978. The overall incidence of persistent primary congenital hypothyroidism (PPCH) during the first 10 years of screening was 1:2,950 live births. The purpose of this study was to ascertain the incidence of congenital extrathyroid anomalies (ETAs) among the infants with PPCH and to compare it with the Israeli Birth Defect Monitoring System data. Among 243 PPCH infants on whom adequate data were available, 38 infants (15.6 %) had associated congenital anomalies. Fourteen infants had congenital cardiac anomalies (5.8 %): VSD (n = 7), PDA (n = 3), PS (n = 2), one mitral insufficiency, and one congenital atrial flutter. Eight children (3.3 %) had congenital dislocation of the hip; their M:F ratio was 3:5 similar to the M:F ratio in CH (unlike the ratio in the general population). Some additional anomalies were considerably more common than in the general population. It is reasonable to assume that teratogenic effects active during organogenesis may affect simultaneously many organs, including the developing thyroid, causing a relatively high percentage of CH infants with congenital ETA.

[Alon]

http: // www.vodn.org/hyperb2003.htm (russ)

http: // pediatrics.aappublications.org/cgi/content/full/114/1/297

[dr. Ira]

http: // www.vodn.org/hyperb2003.htm (russ)

http: // pediatrics.aappublications.org/cgi/content/full/114/1/297

I approve.

[dr. Ira]

We, certainly, suited a -topic with Tatyana Gennadevnoj, and Tatyana Gennadevny's offer to invite Irina to us in section on screening newborns fairly.

In Irina's support I shall notice, that Israel was left with only one clause or article (quoted in Pubmed) on screening (in 90th years), and more likely the fact of necessity of screening and clinic congenital gipotiroza, questions of optimization of terms of treatment there understood. The frequency specified in clause or article, most likely, zavyshennaja-in the beginning all found more, than really is present.

Am J Med Genet. 1992 Sep 1; 44 (1):57-60. Related Articles, Links





Congenital anomalies concomitant with persistent primary congenital hypothyroidism.



Siebner R, Merlob P, Kaiserman I, Sack J.



Department of Paediatrics, Sheba Medical Center, Tel-Hashomer, Israel.



The Israeli national neonatal screening program for congenital hypothyroidism (CH) was initiated in May 1978. The overall incidence of persistent primary congenital hypothyroidism (PPCH) during the first 10 years of screening was 1:2,950 live births. The purpose of this study was to ascertain the incidence of congenital extrathyroid anomalies (ETAs) among the infants with PPCH and to compare it with the Israeli Birth Defect Monitoring System data. Among 243 PPCH infants on whom adequate data were available, 38 infants (15.6 %) had associated congenital anomalies. Fourteen infants had congenital cardiac anomalies (5.8 %): VSD (n = 7), PDA (n = 3), PS (n = 2), one mitral insufficiency, and one congenital atrial flutter. Eight children (3.3 %) had congenital dislocation of the hip; their M:F ratio was 3:5 similar to the M:F ratio in CH (unlike the ratio in the general population). Some additional anomalies were considerably more common than in the general population. It is reasonable to assume that teratogenic effects active during organogenesis may affect simultaneously many organs, including the developing thyroid, causing a relatively high percentage of CH infants with congenital ETA.

Screening is done or made necessarily. But, how much or as far as I understand, the hypothyrosis not always is shown clinically in the first days of a life. For this purpose screening also is necessary. And here, if suspicion vrzniklo on the basis of survey of the child, what I shall wait for results of screening when I can have tomorrow and TSH, T3, T4? By the way, at the son of my friends and have revealed a hypothyrosis, on screening. Up to monthly age nothing differed from other babies, and the icterus, by the way, too was not. And there was one which in the age of 10 hours (at the first survey-he was born at night) looked or appeared suspiciously. Results were in day. And home he has been written out both with the diagnosis, and with treatment.

dr. Ira

[Melnichenko]

100 % and are unequivocal. As the doll - Zhirinovsky, for that and speaks screening to not pass or miss gipotiroz-and more 120 % of-th, that he (gipotiroz neonatal) frequently does not come to light or is not taped clinically.

But we were afflicted with the report, that results of screening become known in Israel through mesjats-it in fact very badly (the bases to be afflicted for itself at us even more, at us term is not less, but it would be desirable to believe that somewhere better).

In the scheme or plan. Offered Alonom fraza-*quot; TO LEARN or FIND out results of screening. Certainly, I more than not against repetition TTG (against research 3 at suspicion on gioptiroz, but it it is details), but unless pediatrists of Israel arrange reception of results of screening through mesjats-or we have not understood something? By the way, and screening is conducted only on primary gipotiroz (TTG) or on secondary too (TTG + over 4)?

[dr. Ira]

100 % and are unequivocal. As the doll - Zhirinovsky, for that and speaks screening to not pass or miss gipotiroz-and more 120 % of-th, that he (gipotiroz neonatal) frequently does not come to light or is not taped clinically.

But we were afflicted with the report, that results of screening become known in Israel through mesjats-it in fact very badly (the bases to be afflicted for itself at us even more, at us term is not less, but it would be desirable to believe that somewhere better).

In the scheme or plan. Offered Alonom fraza-*quot; TO LEARN or FIND out results of screening. Certainly, I more than not against repetition TTG (against research 3 at suspicion on gioptiroz, but it it is details), but unless pediatrists of Israel arrange reception of results of screening through mesjats-or we have not understood something? By the way, and screening is conducted only on primary gipotiroz (TTG) or on secondary too (TTG + over 4)?

How much or As far as I remember, in a month. And that not to me, and in children's consultation (it at us separate service, state) and only, if result positive. Healthy children are observed in children's consultations (up to 3 years), and to me to hospital cash department (something like an out-patient department) come, when fall or are ill. Such system. In d.k. There is a nurse, the doctor of times in a month, but the child each time looks not. Inoculations in d.k, and here with temperature after inoculations-to me. Screening, how much or as far as I know, only on primary. It is possible, certainly to call and find out, but it is such long story what easier to repeat the analysis if there are suspicions.

dr. Ira

[Melnichenko]

Clearly, that parents of healthy children do not receive notices (the norm or rate and is norm or rate). And here reception by parents of sick children (or suspicious on gipotiroz) notices in a month, alas, badly. The beginning of treatment not later than 10 days of day postnatalnoj lives would be optimum.

Certainly, destiny *quot; ?O????uoUO*quot; children not sravnima with destiny *quot; n?O????uoUO*quot;, but in Moscow, according to prof. E.P.Kasatkinoj, only one skriningovaja 7-years girl has IQ 140 (the beginning of treatment for 8 day postnatalnoj lives), the majority - nearby 90, and, alas, a considerable part - below 90... Direct dependence between time of the beginning lecheneija and IQ

[Alon]

I can calm you - screening in Israel works quite normally and, how much or as far as I remember, includes both TSH and FreeT4. Dr. Ira is simple not the first addressee for reception of its or his results (it not its or her function).

Concerning dependence on time of the beginning of treatment and, is raspingly speaking, *quot; degrees ONO?????a*quot; here all is clear, if I am not mistaken, for cases when treatment begins after 4 weeks of a life (and the beginning of treatment up to 4 h weeks is considered normal). And here in the rest, at the well-timed beginning of treatment, with clearness there are problems, i.e. equality IQ with healthy remains, apparently, and in this case in doubt. Here you will correct for me if I am not right.

Concerning *quot; Israeli OO?a*quot; doctor Iry - forget and read new references AAR - all is there clearly enough written.

By the way, children's consultation about which doctor Ira writes, in Israel is called *quot; Tipat Oa?ao*quot;, that means *quot; the Drop ??a*quot;:)

[Melnichenko]

*quot; Here you will correct for me, if I not Oao*quot; - I shall not correct, because it is too much vvodnyh-gravity gipotiroza by the moment of a birth (correlates with a level over 4 - and it or him not all the countries look), \ adequacy of a dose of the appointed or nominated thyroxine, carefulness of the control over the future, carefulness of keeping of a regimen in the future, region of residing (iododefitsit), sotsioekonomichesky the status of family and so forth



So I really do not know, whether there will be a significant advantage to the majority if treatment will be not later than 15 days (England) or 21 day, or 30 days is comprehensible... Speech, certainly, about full-term.

And, by the way about *quot; to a drop ??a*quot; - it is surprising, but the fact thoracal (in milk of mum there is a thyroxine) \ artificial feeding - whether has this value or meaning;importance for congenital gipotiroza (in old time considered or counted, that has) is not analyzed in publications.

Besides greater or big efforts on data gathering about all children-. state registers in view of perchislennyh are necessary are necessary (and. Likely, the factors forgotten still or even).

[Alon]

By the way-



Joanne F. Rovet

Children With Congenital Hypothyroidism and Their Siblings: Do They Really Differ?

Pediatrics 2005; 115: e52-e57.

------------------------------

Abstract



Objective. Although favorable outcome is typically described in follow-up studies of children with congenital hypothyroidism (CH) identified by newborn screening, IQ reductions and persistent cognitive deficits are still reported. These findings are accounted for by disease and treatment variables as well as methodologic factors including choice of comparison group. Although siblings are ideal because they control for genetic and environmental influences, by definition they have different ages when tested, which can also introduce bias. Because we followed children with CH and their siblings over an extended period of time, there were a number of occasions when both groups were tested at the same age. The purpose of this study was to compare the results of children with CH and their unaffected siblings at the same age and with the same test.



Methods. The sample consisted of 42 children with CH detected between 1975 and 1985 and their 42 siblings, all of whom were tested with the McCarthy or Wechsler Intelligence Scale for Children-Revised (WISC-R) intelligence tests. Nineteen pairs of children were evaluated at 6 years with the McCarthy, and 30 pairs of children were evaluated at 7 or 9 years with the WISC-R. Recorded for children with CH were disease etiology, bone age and thyroxine levels at diagnosis, age at onset of treatment, and starting dosage of levothyroxine.



Results. Paired t tests revealed that the CH group scored lower than siblings by 8.1 IQ points on the McCarthy and 6.2 points on the WISC-R. Factors contributing to the size of the CH-sibling IQ difference were (1) the etiology of hypothyroidism, reflecting the larger differences by those with athyreosis or an ectopic gland than dyshormonogenesis, and (2) the starting dosage of levothyroxine, with those initially treated with 8.2 g/kg per day having smaller CH-sibling differences than those given lower starting doses. There were no effects of bone age, thyroxine levels at diagnosis, or age at treatment onset.



Conclusion. Children with CH treated early in life due to newborn screening may have reduced IQ relative to siblings.

[Tanya G]

I can calm you - screening in Israel works quite normally and, how much or as far as I remember, includes both TSH and FreeT4.

I have correctly understood - besides research TTG, definition is included or switched on in screening over 4 also? Interestingly, how much it is in that case pawned in the budget of Israel of money for carrying out of screening... Here the question is lawful - and whether is estimated or appreciated razumnost such expenses if treatment all the same begins late?

[Alon]

Here the question is lawful - and whether is estimated or appreciated razumnost such expenses if treatment all the same begins late?

I about cases of the late beginning of treatment do not know.

[Melnichenko]

Was in Seville Merk - workshop Brain *amp; Thyroid - year 4 as.

I therefrom have born or have taken out a firm unofficial reason, that the digit in 10-14 days is called as a median of start of treatment in the majority of reports.

And only razgovrarivaja with Alonom and Iroj and looking through links, has understood, what there are no comparisons (and how them to spend?) between those whom have started to treat for 8 day and those whom have started to treat on ill-starred 30-th.

Small samples as a whole are very safe, on greater or big I already wrote. Certainly, idea of comparison with sibsami. Resulted or brought Alonom, it is good. But there confuses very old data on screening when in that pore treatment began? How much there was a -test?

There is still a curious nuance.

Absorption of a thyroxine is braked at acceptance by its or his milk, and there were attempts to give or allow a soluble thyroxine, there were disputes or spores on greater or big and *quot; iU??UO*quot; starting doses. Certainly, the basic ideja-would be TTG always normal..



The sample safe publication..

J Pediatr. 2004 Jun; 144 (6):747-52. Related Articles, Links





Comment in:

J Pediatr. 2004 Jun; 144 (6):698-700.



Cognition and behavior at school entry in children with congenital hypothyroidism treated early with high-dose levothyroxine.



Simoneau-Roy J, Marti S, Deal C, Huot C, Robaey P, Van Vliet G.



Endocrinology Service, Sainte-Justine Hospital Research Center, Montreal, Quebec, Canada.



OBJECTIVE: To document cognition and behavior at school entry in these patients. Study design Eighteen children with congenital hypothyroidism (CH; 9 severe and 9 moderate, based on a surface of the knee epiphyses at diagnosis*lt; or *gt; or=0.05 cm (2)) treated from a median of 14 days with a median of 12.0 microg/kg per day of levothyroxine were evaluated at 5 years, 9 months, with the McCarthy Scale and the Questionnaire for Evaluation of Social Behavior, as were 40 control children. RESULTS: The global IQs at 5 years, 9 months, were similar: medians (range) were 102 (87 to 133), 102 (84 to 135), and 115 (88 to 136) (not significant) for severe CH, moderate CH, and control children, respectively. The behavioral scores of CH children were within the normal range. However, the number of times when plasma TSH was *gt; 6.0 mIU/L during treatment was correlated positively with anxiety (P =.02) and inattention (P =.05), whereas the number of times TSH was *lt; 0.8 mIU/L was correlated with lower verbal scores (P =.05). CONCLUSIONS: Children with severe CH treated early with a high dose of levothyroxine have normal global development and behavior at school entry.



But now I shall specially trace data on start of therapy who before all starts to treat, and it is really valid these two weeks of the first month are not so important...

[Alon]

It is necessary to regret only, that we seldom discuss here similar things. It would be more interesting, probably.

[Melnichenko]

It is very important, owing to this conversation there were new ideas. I shall try to suggest to organize the review with accent or stress for terms of the beginning of therapy (t.e 7-30 day) and to spend the metaanalysis (how much or as far as it probably) .ochevidnaja logika-the earlier we treat, the can not receive podtverzhenija because of set privhodjashchih the moments is better (we assorted them) .no all the same neponjatno-if we spend a fence for 3-5 day if a technique fast. If phone is - for what reasons the turn from assays (in fact the answer in a month means otlezhivanie assays in turn) .ja is framed did not see rasschetov, proved. That this or it dvumja-can be neglected three weeks. M.b.. Grigory Anatolevich met something?

[Tanya G]

It is very important, owing to this conversation there were new ideas. I shall try to suggest to organize the review with accent or stress for terms of the beginning of therapy (t.e 7-30 day) and to spend the metaanalysis (how much or as far as it probably) .ochevidnaja logika-the earlier we treat, the can not receive podtverzhenija because of set privhodjashchih the moments is better (we assorted them) .no all the same neponjatno-if we spend a fence for 3-5 day if a technique fast. If phone is - for what reasons the turn from assays (in fact the answer in a month means otlezhivanie assays in turn) .ja is framed did not see rasschetov, proved. That this or it dvumja-can be neglected three weeks. M.b.. Grigory Anatolevich met something?

Galina Afanasevna when I was on a cycle at E.P.Kasatkinoj in 2001, at it or her was aspirantka which under its or her management or manual wrote job - just on a subject... Estimated or Appreciated a state of health and intellectual development of children with vr. gipoitireozom depending on the beginning of therapy.

[Tanya G]

Can, here we shall move? http: // forums./showthread.php? t=13036

Me the truth very much interests - as at others it looks or appears practically...

[Melnichenko]

Here this aspirantki data I also resulted or brought - about the girl with IQ 140. But all job not videla-and the used methods of the analysis in her too I do not know.. How much or As far as I understand, two weeks after prozhenija (but not inside of group - 2 weeks vs 1 mesjats-a little given) were compared doskriningovye-t.e the diagnosis on clinic to the extremity or end of year, and skriningovye-\ \

[Alon]

Can, here we shall move? http: // forums./showthread.php? t=13036

Me the truth very much interests - as at others it looks or appears practically...

Details I promise to specify one of these days.

[Alon]

Has now phoned with minzdravom - on results of screening inform in the age of 5-6 days.