This document provides an overview of neonatal jaundice, including its definition, clinical features, causes, complications, investigations, and management. Some key points include:
- Jaundice is a common condition in newborns caused by accumulation of bilirubin in the skin.
- It results from the normal breakdown of red blood cells in combination with the immature liver's ability to process bilirubin in newborns.
- If left untreated, extremely high bilirubin levels can cause brain damage (kernicterus).
- Treatment involves phototherapy or exchange transfusions in severe cases to lower bilirubin levels.
- Causes of jaundice include physiological causes or
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Neonatal jaundice
1. D R M A N O R I G A M A G E
( M B B S M D D C H M R C P C H )
S E N I O R L E C T U R E R I N P A E D I A T R I C S
F A C U L T Y O F M E D I C A L S C I E N C E S
U N I V E R S I T Y O F S R I J A Y E A R D E N E P U R A
S R I L A N K A
NEONATAL JAUNDICE
3. What is Jaundice?
Yellow color discoloration of the skin and sclera of
newborn babies that results from accumulation of
bilirubin in the skin and mucous membranes.
New born appears jaundiced when serum bilirubin is
more than 7mg/dl
4. What is Bilirubin?
A breakdown product of RBC
Produces un conjugated (indirect) bilirubin bound to
albumin
This metabolized in the liver to produce the
conjugated bilirubin (direct)
Which passes through the gut and excreted in stools
And a portion of it enter the enterohepatic
circulation
6. Overview of Neonatal Jaundice
A common condition requiring medical attention in
newborns.
60% of term and 80% of preterm babies develop
jaundice in the first week of life
10% of breastfed babies are jaundiced at first month
of age
7. Why Newborns are susceptible for Jaundice?
Their RBC has a shorter life span than the adult’s
Their RBC concentration is high as an adaptation to
relatively hypoxic intrauterine life
Hepatic enzyme immaturity for bilirubin conjugation
Increased enterohepatic circulation due to lack of
intestinal flora
8. Jaundice first appears between 24-72 hours of age
Maximum intensity is seen on 4th to 5th day in a term
and 7th day in a preterm neonates
Does not exceed 15mg/dl (255μmol/l)
Clinically undetectable after 14 days in term baby
It is a diagnosis by exclusion
Features of Physiological jaundice
10. Features of Pathological Jaundice
Clinical jaundice within 24 hrs of life
Total serum bilirubin >15mg/dl after 24hrs of life
Total serum bilirubin (TSB) increasing by
>5mg/dl/day or 0.5mg/dl/hr
Conjugated bilirubin >20% of TSB
Clinical jaundice persisting more than 2 weeks in a
term or more than 3 weeks in a preterm neonate.
12. Early Onset Jaundice
Jaundice within the first 24 hours is commonly
result from significant hemolysis. This is a neonatal
emergency and a serum Bilirubin measurement
should be obtained within 2 hours
Haemolytic disease of the newborn – Rh, ABO,
Minor blood group incompatibility.
15. Identification of a new born with risk factors for
Bilirubin encephalopathy
Gestational age less than 38 weeks
A previous history with neonatal jaundice requiring
phototherapy
Mother’s intention to breast feed exclusively
Visible jaundice in the first 24 hours of life
16. Kernicterus
Encephalopathy resulting from deposition of
bilirubin in brain stem, hippocampus, cerebellum
and brainstem nuclei (globus pallidus and sub
thalamic nuclei )
17. Features of Acute bilirubin Encephalopathy
Hypotonia
Lethargy
Poor feeding
Irritability
Hypertonia of extensor muscles
Opisthotonos
Respiratory distress
Shrill high pitched cry
Apnoea
Loss of moro reflex
Seizures
Coma
18. Long term Sequalae of bilirubin Encephalopathy
Extrapyramidal disturbances
High frequency sensorineural hearing disturbances
Upward gaze palsy
Athetoid cerebral palsy
19. Assessing the levels of serum bilirubin
Visual inspection
Transcutaneous Bilirubinometry
Invasive blood sampling
20. Visual Inspection
• Jaundice restricted
to the face and trunk
– TSB <12mg/dl
• On hands and feet
– TSB > 15 mg/dl
21. Problems encountered in visual inspection
Difficult to detect in preterm infants
Can be missed in dark skinned babies
Unreliable under artificial light
Cease to use after initiating phototherapy
Unable to asses the severity
Accuracy is not improved by the assessment of the
Cephalo caudal progression of dermal jaundice
22. It is essential to estimate the bilirubin
level whenever a baby is visibly
jaundiced
24. New developments…
“ BiliCam ” - application used via a smartphone
camera to assess the severity by a photograph
25. Invasive blood sampling
By the use of Bilirubinometer by direct spectrometry
Plotted in threshold graphs appropriate for the
gestational age to decide on the treatment
26. Investigations of jaundice in a newborn
Early onset jaundice
Blood group and DAT
Haemtocrit and FBC
Blood picture
Infection screen if indicated
serology for congenital infections
Urine for CMV culture
Stool for virology
G-6 PD screen
Red cell enzyme studies
27. Prolonged Jaundice
Total and conjugated bilirubin
Thyroid profile
Urine culture
Urine for reducing substances
Liver function tests
Alpha-1 antitrypsin assay and phenotype
Cystic fibrosis DNA screen
Immuno -Reactive trypsin
plasma cortisol level
Serum amino acid level
28. Management
Starts with prevention
Support to initiate early feeding pattern
Phototherapy
Pharmacological agents – high dose IVIG to
suppress haemolysis
Exchange transfusion
31. Optimal use of Phototherapy
Efficacy of phototherapy depends on the:
- Dose – 25 -30 µW/cm³/nm
- Wavelength of light – blue light in 450 nm
- Proportion of the infant’s surface area
32. Convenient and safe means of lowering serum
bilirubin
Only effective as bilirubin enters the skin at serum
levels more than 80µmol/l
Converts bilirubin to water soluble photo isomers
like Lumirubin thus excreted via urine
Maximal effect is during first 24-48 hours of use
In the absence of hemolysis reduce serum bilirubin
by 25% to 50%
33. Checking the response of Phototherapy..
After starting phototherapy SBR checked 4- 6 hourly
until SBR is stable or falling
And thereafter every 6- 12 hourly
When SBR has fallen to more than 50µmol/l below
the phototherapy threshold, single phototherapy
should be stopped
SBR checked for rebound after 12 – 18 hours
34. Cautions and Requirements during Phototherapy
Individual assessment of fluid requirement
Good thermoregulation
Monitoring of stool frequency and urine output
Eyes of the babies should be covered to avoid retinal
damage
35. Indications for multiple phototherapy
SBR is within 50µmol/l below the threshold for
which the exchange transfusion is needed
SBR is rising rapidly more than 8.5µmol/l/hour
despite single phototherapy
38. Complications of phototherapy
Diarrhea- as a result of irritant effect of photo
isomers on the bowel wall
Increased fluid loss via the skin
Temperature instability
Erythematous rashes
Tanning
Bronze baby syndrome
39. Pharmacological agents
Treatment with high dose IVIG for HDFN and ABO
iso -immunization reduces the need for exchange
transfusion
Dosage 0.5 g/kg over 2- 4 hours
40. Exchange transfusion
Double volume exchange transfusion (2×80ml/kg)
Blood cross matched with mothers serum and babies
blood
Indications
Infants who fails to respond to optimal phototherapy
Signs and symptoms of acute bilirubin encephalopathy
41. Investigations prior to ET
Haemoglobin
Reticulocyte count
Blood picture for evidence of haemolysis
Blood group – mother and baby
Direct Coomb’s test
SBR
42. Umbilical vessels are the preferred access
Use blood less than 5 days old
Use acid citrate dextrose (ACD), or citrate phosphate
dextrose (CPD) as the anticoagulant
Electrolytes, blood gases, vital sighs should be
monitored during the transfusion
43. o During exchange transfusion do not:
o stop continuous multiple phototherapy
o Perform single volume exchange
o Use albumin priming
o Routinely administer intravenous calcium
Following exchange transfusion
o Maintain continuous multiple phototherapy
o Measure serum bilirubin level within 2 hours and
manage according to the threshold tables
44. Complications of Exchange transfusion
Exchange transfusion carries significant mortality(0.3%) and
morbidity(5%)
Some common complications are;
Thrombocytopenia
Hypocalcaemia
Hypotension
Venous thrombosis
Hypokalemia
Hypoglycemia
Catheter malfunctions
45. References
Management of neonatal jaundice: N Kevin Ives -
Journal of Paediatric and child health 25:6 June
2016
National guidelines for new born care- volume 2
NICE guidelines on Neonatal Jaundice- 2010
Illustrated textbook of Paediatrics 5th Edition