neonatal jaundice - gmch.gov.in lectures/pediatrics/jaundice.pdf · teaching aids: nnf nj - 2...

Neonatal Jaundice

NJ - 2Teaching Aids: NNF

Neonatal Jaundice

Visible form of bilirubinemia – Adult sclera >2mg / dl– Newborn skin >5 mg / dl

Occurs in 60% of term and 80% of preterm neonatesHowever, significant jaundice occurs in 6 % of term babies

NJ - 3Teaching Aids: NNFBilirubin metabolism

Hb → globin + haem1g Hb = 34mg bilirubin

Non – heme source1 mg / kg

Bilirubin glucuronidase

Bilirubin

BilirubinLigandin(Y - acceptor)

Bil glucuronide

Intestine

Bil glucuronide

Stercobilin

bacteria

β glucuronidase


Clinical assessment of jaundice

Area of body Bilirubin levelsmg/dl

Face 4-8Upper trunk 5-12Lower trunk & thighs 8-16Arms and lower legs 11-18Palms & soles > 15


Physiological jaundice

CharacteristicsAppears after 24 hoursMaximum intensity by 4th-5th day in term & 7th day in pretermSerum level less than 15 mg / dlClinically not detectable after 14 daysDisappears without any treatment

Note: Baby should, however, be watched for worsening jaundice


Why does physiological jaundice develop?

Increased bilirubin loadDefective uptake from plasmaDefective conjugationDecreased excretionIncreased entero-hepatic circulation

Teaching Aids: NNF NJ- 7

Age in Days

TermPreterm

1 2 3 4 5 6 10 11 12 13 14

15

10

5

Bili

rubi

n le

vel

mg/

dl

Course of physiological jaundice


Pathological jaundice

Appears within 24 hours of ageIncrease of bilirubin > 5 mg / dl / daySerum bilirubin > 15 mg / dlJaundice persisting after 14 daysStool clay / white colored and urine staining clothes yellowDirect bilirubin> 2 mg / dl


Causes of jaundice

Appearing within 24 hours of ageHemolytic disease of NB : Rh, ABOInfections: TORCH, malaria, bacterialG6PD deficiency

Appearing between 24-72 hours of lifePhysiologicalSepsisPolycythemiaConcealed hemorrhageIntraventricular hemorrhageIncreased entero-hepatic circulation


Causes of jaundiceAfter 72 hours of age

SepsisCephalhaematomaNeonatal hepatitisExtra-hepatic biliary atresiaBreast milk jaundiceMetabolic disorders


Risk factors for jaundice

JAUNDICEJ - jaundice within first 24 hrs of lifeA - a sibling who was jaundiced as neonate U - unrecognized hemolysisN – non-optimal sucking/nursingD - deficiency of G6PDI - infectionC – cephalhematoma /bruisingE - East Asian/North Indian


Common causes in India

Exaggerated physiologicalBlood group incompatibility – ABO,RhG6PD deficiencyBruising and cephalhaematomaIntrauterine and postnatal infectionsBreast milk jaundice


Approach to jaundiced baby

Ascertain birth weight, gestation and postnatal ageAsk when jaundice was first noticed Assess clinical condition (well or ill)Decide whether jaundice is physiological or pathologicalLook for evidence of kernicterus* in deeply jaundiced NB

*Lethargy and poor feeding, poor or absent Moro's, opisthotonus or convulsions


Workup

Maternal & perinatal historyPhysical examinationLaboratory tests (must in all)*– Total & direct bilirubin*– Blood group and Rh for mother and baby*– Hematocrit, retic count and peripheral smear*– Sepsis screen– Liver and thyroid function– TORCH titers, liver scan when conjugated

hyperbilirubinemia


Management

Rationale: reduce level of serum bilirubin and prevent bilirubin toxicityPrevention of hyperbilirubinemia: early feeds, adequate hydrationReduction of bilirubin levels: phototherapy, exchange transfusion, drugs


Principle of phototherapy

Native bilirubin Photo isomers of bilirubin

Insoluble Soluble

450-460nm

of light


Phototherapy equipment

White light tubes 6-8*/ 4 blue light tubesCradle or incubatorEye shades

*May use 150 W halogen bulb

Babies under phototherapy

Baby under conventional phototherapy

Baby under triple unit intense phototherapy


Phototherapy

TechniquePerform hand washPlace baby naked in cradle or incubatorFix eye shadesKeep baby at least 45 cm from lights, if using closer monitor temperature of babyStart phototherapy


Phototherapy

Frequent extra breast feeding every 2 hourlyTurn baby after each feedTemperature record 2 to 4 hourlyWeight record- dailyMonitor urine frequencyMonitor bilirubin level


Side effects of phototherapy

Increased insensible water lossLoose stoolsSkin rashBronze baby syndromeHyperthermiaUpsets maternal baby interaction May result in hypocalcemia


Choice of blood for exchangeblood transfusion

ABO incompatibility– Use O blood of same Rh type, ideal O cells

suspended in AB plasmaRh isoimmunization– Emergency 0 -ve blood

Ideal 0 -ve suspended in AB plasma or baby's blood group but Rh -ve

Other situations– Baby's blood group

Phototherapy


Exchange Transfusion



Prolonged indirect jaundice

Causes

Crigler Najjar syndrome

Breast milk jaundice

Hypothyroidism

Pyloric stenosis

Ongoing hemolysis, malaria


Conjugated hyperbilirubinemia

SuspectHigh colored urineWhite or clay colored stool

CautionAlways refer to hospital for investigations so that

biliary atresia or metabolic disorders can bediagnosed and managed early


Conjugated hyperbilirubinemia

Causes Idiopathic neonatal hepatitisInfections -Hepatitis B, TORCH, sepsisBiliary atresia, choledochal cystMetabolic -Galactosemia, tyrosinemia, hypothyroidismTotal parenteral nutrition

neonatal jaundice - gmch.gov.in lectures/pediatrics/jaundice.pdf · teaching aids: nnf nj - 2...

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