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Approach to neonatal jaundice


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Approach to neonatal jaundice

  1. 1.  Jaundice is the visible manifestation of increased level of bilirubin in the body. It is not a disease rather a symptom of diseases. In adults sclera appears jaundiced when serum bilirubin exceeds 2 mg/dl. However it is difficult to see sclera in newborn due to difficulty in opening eye. But in new born it is very easy to see jaundice in skin.
  2. 2.  Important problem in the 1st week of life Almost all neonates (60% Term and 80% Preterm) will have bilirubin > 5 mg/dl in the 1st week of life and become visibly jaundiced, vast majority being benign Some of the term babies (8 to 9%) have levels exceeding 15 mg/dl in 1st 7 days of life. High bilirubin level is toxic to the developing CNS
  3. 3. A women who delivered at homepresented on her 5th postpartum day atpediatric OPD complaining that her babylooked yellow.
  4. 4. Hyperbilirubinemia in the first week of life isusually of the indirect variety.1. Appearing at birth or within 24 hours of age › Hemolytic disease of newborn › Infections: intrauterine viral, bacterial; malaria › G-6PD deficiency
  5. 5. 2. Appearing between 24-72 hours of life › Physiological › Sepsis neonatorum › Polycythemia › Concealed hemorrhages: cephalhematoma, subarachnoid bleed, IVH. › Increased enterohepatic circulation
  6. 6. 3. Appearing after 72 hrs and within 1st week a) Sepsis neonatorum (4th - 7th days) b) Syphilis c) Toxoplasmosis
  7. 7. 4. Jaundice appearing after1 weeka) Prolonged direct Jaundice › Neonatal hepatitis (common) › Extrahepatic biliary atresia › Breast milk jaundice › Metabolic disorders › Intrahepatic biliary atresia › Amino acid toxicity › Inspissated bile syndrome (uncommon)
  8. 8. Jaundice appearing after1 week contd…b) Prolonged Indirect Jaundice› Criggler Najjar Syndrome› Breast milk jaundice› Hypothyroidism› Pyloric stenosis› Ongoing hemolysis, malaria
  9. 9. On history, the baby started turning yellowon his 2nd day. The baby was a full termmale child delivered at home. Baby iscurrently 120 hours old. There was no historyof any maternal illness during pregnancy.Delivery was uneventful. Baby immediatelycried after birth and was immediatelybreastfed.
  10. 10. Baby passed meconium on his first day.Urine is normal with no staining of nappies.Stool also is normal in colour.On past history, there was no H/O history ofmalaria during pregnancy.On family history, there was no H/O ofjaundice, liver disease. Previous sibling hadno history of neonatal jaundice.
  11. 11. Baby was well looking, feeding well, vitalswere normal, temperature was normal.There were no rashes and petechiae in thebody. Baby weighed 3 kg. Icterus waspresent. Pallor was Absent. On abdominalexamination no organomegaly waspresent. Chest was clear and CVSexamination was normal.
  12. 12. 1. Dermal staining (By karmer) progresses from head to toe › Examined in good day light skin of forehead, chest, abdomen, thigh, legs, palms, and soles › Blanched with digital pressure and the underlying color of the skin and subcutaneous tissue should be noted.2. Transcutaneus bilirubinometer
  13. 13. In new born babies bilirubin metabolism isimmature which results in the occurrenceof hyperbilirubinemia in the first few days oflife. Also there is increased bilirubin load onthe hepatic cell due to physiologicalpolycythemia.
  14. 14. Immaturity could be at various steps ofbilirubin metabolism like:  Defective uptake from plasma into liver cell  Defective conjugation  Decreased excretion  Increased entero-hepatic circulation
  15. 15.  First appears between hours of age Maximum intensity seen on 4-5th day in term and 7th day in preterm neonates Does not exceed 15 mg/dl Clinically undetectable after 14 days. No treatment is required but baby should be observed closely for signs of worsening jaundice.
  16. 16. Presence of any of the following signsdenotes that the jaundice is pathological. Clinical jaundice detected before 24 hours of age Rise in serum total bilirubin by more than 5 mg/dl/ day (>5mg/dl on first day , 10 mg/dl on second day and 12- 13 mg/dl thereafter in term babies)
  17. 17.  Serum bilirubin more than 15 mg/dl Clinical jaundice persisting beyond 14 days of life Clay/white colored stool and/or dark urine staining the nappy yellow Direct bilirubin >2 mg/dl at any timeTreatment is required in the form ofphototherapy or exchange bloodtransfusion. One should investigate to findthe cause of pathological jaundice.
  18. 18. Clinical Jaundice Measure Billirubin > 12 mg/dl and < 12 mg/dl and infant < 24 hr old infant > 24 hr old Follow bilirubin Coomb’s test levelPositive Negative Identify antibody Direct Rh, ABO etc bilirubin
  19. 19. Direct bilirubin > 2 mg/dl < 2 mg/dl Consider HepatitisIntrauterine,viral,or Hematocrit Toxoplasmatic inf. Biliary obstr. Sepsis Galactosemia Normal or low CholestasisHemochromatosis High (Polycythemia)
  20. 20. Normal or Low RBC morphology Reticulocyte Count NORMAL Enclosed hemorrhage ABNORMAL Increased enterohep. circ. SpherocytosisBreast milk, Hypothyroidism, Elliptocytosis etc. Crigler-Najjar syndrome ABO Incompatibility Infant of diabetic mother Red cell enzyme def RDS, Asphyxia Alpha thallasemia Infections, Drugs(eg Drugs(eg penicillin novobiocin), galactosemia
  21. 21. Investigations were done. Serum totalbilirubin was found to be 10 mg/dl. Thebaby was diagnosed as a case ofphysiological Jaundice. Parents werecounseled. The baby was discharge andkept on follow up for serial analysis ofBilirubin level.
  22. 22. 1. Bhutani V.K., Johnson Lois H., Keren Ron Diagnosis and management of hyperbilirubinemia in term neonates for a safer first week, Pediatric clinic of North America, Common issues and concerns in Newborn Nursery, Part II Aug 2004, vol 5, No. 42. Gowen CW Jr. Anemia and hyperbilirubinemia. In: Kliegman R. Nelson Essentials of Pediatrics. 5th ed. Philadelphia, Pa.: Elsevier Saunders; 2006:318.3. Paul Vinod K, Deorari Ashok K, Agrawal Ramesh et all, Newborn infants, Ghai Essential Pediatrics, 2009, 147-514. Internet