Neonatal Jaundice (Malaysia)

1. NEONATAL JAUNDICE
YEE WEI HOONG
121303147
31B (L1)
1

2. DEFINITION
• Jaundice is a yellowish discolouration of
skin, sclerae, mucous membranes & nails
from accumulation of bilirubin.
• Hyperbilirubinemia refers to an excessive
level of bilirubin in blood.
2

3. Neonatal Jaundice
• One of the most common medical
conditions in newborn babies
• All babies have transient rise in
serum bilirubin, but only 75% are
visibly jaundiced.
• Jaundice is clinically detectable when
serum bilirubin levels are >5mg/dL
(85 umol/L)
• Jaundice is more common in Asian 3

4. Day 1 Day 7 Day 14/21
PATHOLOGICAL
jaundice
PHYSIOLOGICAL
jaundice
PROLONGED
jaundice
Time Frame for
Jaundice
4

5. CLASSIFICATIONS
• Physiological
1. Appears after 24hrs
2. Maximum intensity by 3rd -5th day in term, 7th day in
preterm
3. TSB <15mg/dL (<255umol/L)
4. Not detectable clinically after 14days
5. No underlying cause
6. Disappears spontaneously
• Pathological
1. Appears within 24hrs of age
2. Serum bilirubin level increase >6mg/dl/day
3. TSB >20mg/dL(340umol/dL)
4. Conjugated/Direct bilirubin >2mg/dL(34umoLdL) 5

6. Pathophysiology of Physiological
Jaundice
1. Decreased erythrocyte life span (80 to 90 days) in a full
term infant
2. Increased erythrocyte volume
3. Increased bilirubin load on the hepatic cell
4. Defective uptake from plasma into liver cell – decreased
ligandin
5. Defective conjugation - relatively low activity of the
enzyme glucuronosyltransferase which normally converts
unconjugated bilirubin to conjugated bilirubin
6. Low conversion of bilirubin to urobilinogen by the
intestinal flora resulting in higher entero-hepatic
circulation
7. Decreased excretion 6

7.  RBC vol &  RBC survival
 Bil monoglucoronide
 Bil Diglucoronide
UCB
ProductionTransport
Uptake
Excretion
Conjugatio
n
 ineffective erythropoiesis &  haem
turnover
Non availability of
albumin binding sites
Defective conjugation
 Ligandin
Decreased
excretion
 gut motility
Poor
evacuation
 beta glucoronidase,  intestinal
bacteria
 BILIRUBIN load
Defective uptake from
plasma
 Entero-hepatic
circulation
Bilirubin Load Causing
Jaundice in Newborn
7

8. CAUSES OF PATHOLOGICAL
JAUNDICE
1. Haemolytic disease of newborn: Rh, ABO &
minor group (anti-Kell, Duffy)
incompatibility
2. Infections: Intrauterine infection
(Bacterial, viral)
3. Membrane defects: Spherocytosis,
elliptocytosis
4. RBC enzyme defects: G6PD deficiency,
pyruvate kinase deficiency
5. Polycythemia
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9. NNJ & Mother’s Knowledge
• A Malaysian study found that less
than 50% of the mothers had good
knowledge & awareness about the
risks & complications of NNJ.1
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1. Boo NY, et al. Med J Malaysia. 2011 Aug;66(3):239-243

10. MONITORING
• Extract (1) from Malaysia CPG :
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11. MONITORING
• Extract (2) from Malaysia CPG :
11

12. MONITORING
• Extract (3) from Malaysia CPG :
12
82. Division of Family Health Development, Ministry of Health. Integrated Plan for Detection and
Management of Neonatal Jaundice. Putrajaya: MoH; 2009

13. MONITORING
• Extract (4) from Malaysia CPG :
13

14. P.P.A.P Physiological, Pathological
and Prolonged
14
Physiological
Jaundice
Pathological
Jaundice
Prolonged
jaundice
Starts within 24
hours
Starts after 24 hours;
usually disappear by
14th day
Jaundice lasting >14
days
MIX &
MATCH!!!

15. Maybe Previous Q was too
easy…Try This Pulak.
In the development of physiological NNJ, there is:
a.decreased bilirubin load F
b.defective uptake of bilirubin from
plasma
T
c.defective conjugation T
d.increased excretion F
e.decreased entero-hepatic circulation F
15

16. Three Components of
Assessment
• History
• Physical Examination
• Lab Investigations
*Phototherapy must always be started
while awaiting further assessment &
investigation
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17. Objectives of Proper Assessment
(History, Physical Examination, Lab
Investigations)
17
End Point
Prevention of
bilirubin
neurotoxicity
(acute/
chronic)
To identify
Risk Factors
(for severe NNJ
and neurotoxicity)
Severity of
NNJ
(level of SB or
extent of
hemolysis)
Complications
(signs of ABE)
To decide on
Management
(phototherapy,
exchange
transfusion)
Follow-up
(ABR, MRI,
development)
But not at the cost of overinvestigating or overtreating low risk
babies

18. 1. Risk Factor Identification
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19. 2. ASSESSMENT OF
SEVERITY
• Visual assessment
• Transcutaneous measurement
• Analysis of blood serum
19

20. VISUAL ASESSMENT-
KRAMER’s RULE
Kramer’s rule describes the relationship
between serum bilirubin levels & the
progression of skin discolouration
20

21. Transcutaneous
bilirubinometer (TcB)
• The transcutaneous bilirubinometer is a hand-held
device that measures the amount of bilirubin in the
skin.
Bilicheck (Philips)
Does not require any disposable material & less time consuming
JM 103 (Draeger)
21

22. Serum Bilirubin (SB)
Measurement
• Gold standard for detecting & determining the
level of hyperbilirubinaemia.
• May be estimated on either a capillary or a
venous blood sample.
• Blood sample should be analysed as soon as
possible & should be shielded from light during
transport (exposure to light rapidly &
significantly decreases bilirubin).
• Remove phototherapy prior to sample collection.
22

23. CPG says…
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24. 3. Assessing
Complications
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25. Dangers of Hyperbilirubinemia
• If untreated, it will lead to acute & chronic bilirubin
encephalopathy, eventually kernicterus.
• C/F:
 Refusal of feeds, shrill cry, setting sun sign, convulsions,
retrocollis & opisthotonus
 Sluggish Moro’s response, lethargy, poor feeding
 Preterm – Non specific. Die due to apnoeic attacks
 Infancy – Athetoid cerebral palsy, choreo-athetosis, brownish
staining of teeth, dental dysplasia, deafness, paralysis of upward
gaze, intellectual retardation & learning disabilities
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26. 26
Images taken from: Vinod K, et al. Bilirubin Neurotoxicity in Preterm Infants: Risk and Prevention. J
Clin Neonatol. 2013 Apr-Jun; 2(2): 61–69.

27. Acute Bilirubin
Encephalopathy (ABE)
• ABE: Changes of mental (behavioural)
status & muscle tone during the neonatal
period when the baby is having
hyperbilirubinaemia.
• Identifying & Monitoring of ABE:
• Term Babies: Use BIND Score
• Preterm Babies: Difficult, as signs are subtle.
Auditory Brainstem Response (ABR) could be
used.
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28. BIND
Score
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29. Indications for Referral to
Hospital
• Jaundice within 24hours of life
• All babies that require phototherapy
• Jaundice below umbilicus
• Jaundice extending to soles and feet
• Rapid increase of bilirubin level (>0.5mg/h)
• Diagnosed with G6PD deficiency
• Haemolytic disorder
• Symptoms and signs of sepsis
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30. Investigations
• *Total serum bilirubin
• *G6PD status
• Others as indicated:
-infant’s blood group
-Maternal blood group
-Direct coombs’ test (indicated in day 1 jaundice and
severe jaundice)
-FBC, reticulocyte count, peripheral blood smear
-Blood culture, urine microscopy, and culture (infection
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31. TREATMENT
1. Phototherapy
• Light with wavelenght of 450nm convert
unconjugated bilirubin into harmless water soluble
pigment excreted predominantly in the urine
2. Exchange Transfusion
• Twice the infant’s blood volume 2x80ml/kg is
exchange
3. IVIG (Intravenous immunoglobulin)
• high dose IVIG (0.5-1 gm/kg over 2hours) reduce the need for ET in Rh
and ABO hemolytic disease
• Give as early as possible in hemolytic disease with positive Coomb’s test or
when the serum bilirubin increasing despite intensive phototherapy.
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32. Hmm…Final Q
• Following vessels can be utilised for
exchange transfusion, except:
A. Femoral Vein
B. Umbilical Artery
C. Umbilical Vein
D. Subclavian Vein
E. Peripheral Artery
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33. Measures to Prevent Severe
Neonatal Jaundice
• Promote & support breastfeeding.
• Advise a frequency of 8 to 10 feedings per day
• Formula milk for term infants should be 1 to 2 ounce every 2 to
3 hrs in the 1st week.
• If phototherapy in infants with hemolytic jaundice is initiated
early and discontinue before infant 3-4 days old, must monitor
for rebound jaundice and adequacy of breast feeding within the
next 24-48 hours.
• Routine supplements with water or dextrose water will not help
prevent hyperbilirubinemia
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34. Follow up
• All infant discharge < 48hrs after birth should be
monitor in ambulatory setting or at home
• Infants with risk factors for severe neonatal
jaundice, early follow up is a must to detect
rebound jaundice
• Infant with hemolytic diseases not requiring ET
should be closely followed up for anemia until risk
of ongoing hemolysis is minimal.
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35. REFERENCES
1. Malaysia Clinical Practice Guidelines:
Management of Neonatal Jaundice, 2nd
edition, 2014.
2. Paediatric Protocol. 3rd ed: KKM,2015
3. Tom Lissauer, Illustrated TextBook of
Paediatrics, 4th ed.2012
4. Nelson essential of pediatrics.
5. http://emedicine.medscape.com/article/9
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