2. INTRODUCTION
Jaundice is the visible manifestation of chemical
bilirubinemia.
In adults sclera appears jaundiced when serum bilirubin
exceeds 2 mg/ dl.
In neonates, evaluation of sclera is difficult because of
physiological photophobia.
Icterus, however, becomes apparent on the skin when
serum bilirubin reaches more than 5 mg/ dl.
Almost all neonates (60% Term and 80% Preterm) will
have bilirubin greater than 5 mg/ dl in the first week of life
and about 6% of term babies will have levels exceeding
15 mg/ dl.
3. NEONATAL JAUNDICE
(HYPERBILIRUBINEMIA
• Definition: Hyperbilirubinemia refers to an
excessive level of accumulated bilirubin in the blood
and is characterized by jaundice, a yellowish
discoloration of the skin, sclerae, mucous
membranes and nails.
• Unconjugated bilirubin = Indirect bilirubin.
• Conjugated bilirubin = Direct bilirubin.
5. It is caused by a raised level of bilirubin, a breakdown product of
red blood cells.
Reasons for elevated bilirubin in newborns are:
• The hemoglobin concentration is high at birth so there is
considerable heme degradation
• Lifespan of newborn red blood cells is shorter than that of adult
red blood cells
• Immaturity of liver enzymes impairs bilirubin conjugation and
excretion
• Absorption of unconjugated bilirubin by intestines
(enterohepatic circulation).
7. ASSESSMENT OF JAUNDICE
Clinic al criteria:
It is very widely used and utilizes the principle that clinical
jaundice first becomes obvious in the face followed by a
downward progression as it increases in intensity.
Assessment of jaundice should be done in natural light.
The finger is pressed on the baby's skin, preferably over a
bony part, till it blanches.
The underlying skin is noted for yellow color. Extent of
jaundice thus detected gives a rough estimate of serum
bilirubin.
Clinical estimation of bilirubin by experienced person,
though reliable, has to be confirmed by laboratory
methods.
8. CLINICAL ASSESSMENT OF JAUNDICE
Area of body Bilirubin levels
mg/dl (*17=umol)
1- Face -4-8
2- Upper trunk -5-12
3- Lower trunk & thighs- 8-16
4- Arms and lower legs -11-18
5- Palms & soles -> 15
9. PHYSIOLOGICAL JAUNDICE
Immaturity in bilirubin metabolism at multiple steps results
in the occurrence of hyperbilirubinemia in the first few days
of life. These are:
Increased bilirubin load on the hepatic cell
Defective uptake from plasma into liver cell
Defective conjugation
Decreased excretion
Increased entero-hepatic circulation
10. CHARACTERISTICS OF PHYSIOLOGICAL
JAUNDICE
First appears between 24-72 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
11. PATHOLOGICAL JAUNDICE
Presence of any of the following signs denotes that the
jaundice is pathological.
Treatment is required in the form of phototherapy or
exchange blood transfusion.
One should investigate to find the cause of pathological
jaundice.
• Clinical jaundice detected before 24 hours of age
• Rise in serum bilirubin by more than 5 mg/ dl/ day
• 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
clothes yellow
• Direct bilirubin >2 mg/ dl at any time
12. CAUSES OF JAUNDICE
Hyperbilirubinemia in the first week of life is usually of
the indirect variety.
Causes are usually classified based on the time of
onset of jaundice. While referring a baby with jaundice
make sure that either the mother is referred or mother's
blood sample is sent.
13. 1. APPEARING WITHIN 24 HOURS OF AGE
Hemolytic disease of newborn:
Rh, ABO and minor group incompatibility
Infections:
a. intrauterine viral,
b. bacterial;
c. malaria
G-6PD deficiency
14. .APPEARING BETWEEN 24-72 HOURS OF LIFE
Physiological
Sepsis neonatorum
Polycythemia
Concealed haemorrhages:
cephalhematoma,
subarachnoid bleed,
IVH.
Increased enter hepatic circulation
15. APPEARING AFTER 72 HOURS
Sepsis neonatorum'
Neonatal hepatitis
Extra hepatic biliary atresia
Breast milk jaundice
Metabolic disorders
16. RISK FACTORS OF JAUNDICE
A simple pneumonic for risk factors is JAUNDICE
J - Jaundice within first 24 hrs of life
A - A sibling who was jaundiced as neonate
U - Unrecognized hemolysis
N – Non-optimal sucking/nursing
D - Deficiency of G6PD
I - infection
C – Cephalhematoma /bruising
E - East Asian/North Indian
17. ALTERED PHYSIOLOGY
RBCs destruction
Bilirubin into circulation
Combines with Albumin
Unconjugated or
Indirect bilirubin
In the Liver converted into
Direct or conjugated water
soluble bilirubin
Enzymes of bile
in the intestine
Execrated in
stool
Or
Hydrolyzed to
unconjugated
Reabsorbe
d
to liver
18. CLINICAL EXAMINATION OF JAUNDICE
Dermal staining of bilirubin described by Kramer may be used as a clinical
guide to the level of jaundice.
Dermal staining in newborn progresses in a cephalocaudal direction.
The newborn should be examined in good daylight. The skin should be
blanched with digital pressure and the underlying color of skin and
subcutaneous tissue should be noted.
The severity of jaundice cannot be reliably assessed by clinical Examination.
19. If jaundiced, also check for:
Is the newborn term or preterm?
Basic pathophysiology of jaundice is same in term and preterm neonates but at
lower gestation babies are at higher risk of developing hyperbilirubinemia and
require closer surveillance and monitoring.
Is there evidence of hemolysis?
In the setting of Rh or less frequently ABO incompatibility, onset of
jaundice within 24 hours, presence of pallor and hydrops, presence of
hepatosplenomegaly, presence of hemolysis on the peripheral blood smear,
raised reticulocyte count (>8%), rapid rise of bilirubin (>5 mg/dl in 24 hours
or >0.5 mg/dl/hr) or a suggestive family history of significant jaundice should
raise a suspicion of hemolytic jaundice.
20. Does the infant have an underlying serious disease? (sepsis,
Galactosemia)
Presence of lethargy, poor feeding, failure to thrive, hepatosplenomegaly,
temperature instability or apnea may be a marker of an underlying serious
disease.
Does the infant have cholestatic jaundice?
Presence of jaundice (>10 mg/dl) beyond 3 weeks, presence of dark urine
(staining the clothes) or pale colored stools would suggest cholestatic
jaundice.
21.
22. INVESTIGATIONS
Total bilirubin, Direct bilirubin, Indirect bilirubin
Reticulocyte count, and smear for red cell morphology.
Blood packed cell volume or hematocrit.
Blood group (mother and baby).
Sepsis Screen
Liver function and Thyroid function tests
TORCH Screening
Direct antibody test (DAT or Coombs test).
G6PD testing
Microbiological cultures of blood, urine and/or cerebrospinal fluid for infection
23. MANAGEMENT
The need for treatment is ascertained by plotting the total bilirubin level on a
graph of bilirubin against age in hours. This will determine if:
No treatment is needed
Repeat bilirubin is required in 6 – 12 hours
Phototherapy or exchange transfusion is indicated.
Treatment will change according to the absolute level of bilirubin reached and the
rate of rise on serial measurements (if bilirubin rising > 0.5 mg/dL/hour).
Different cut - off criteria are used for preterm infants, for whom the treatment
threshold is lower
24. PHOTOTHERAPY
This involves exposure of the naked baby to blue, cool
white or green light of wave length 450-460 nm.
The light waves convert the bilirubin to water soluble
nontoxic forms which are then easily excreted.
Every attempt should be made to find out the cause of
jaundice.
The advantages of phototherapy are that it is noninvasive,
effective, inexpensive and easy to use.
25. Clinical assessment of bilirubin level should not be relied
upon in an infant under phototherapy.
Frequent feeding every 2 hrly and change of posture
should be promoted in an infant receiving phototherapy.
Eye shades should be fixed.
External genitalia may be covered as long as the infant is
receiving phototherapy.
Additional oral intake of plain water or glucose water is
neither recommended nor necessary
29. MANAGEMENT OF NEONATAL HYPERBILIRUBINEMIA IN
LOW BIRTH WEIGHT BABIES BASED ON BILIRUBIN LEVELS
(MG/DL)
30. TECHNIQUE
i. Six to eight daylight tubes or four blue tubes are mounted
on a stand and all electrical outlets are well grounded.
Inexpensive commercial phototherapy units are freely
available. Tubes are changed after every 1000 hours or 3
months of use. One may use 150 watt halogen bulb (life
1000 hours) for providing effective phototherapy. Blue CFL
lamps may also be used which should be changed every
3000h.
ii. Check flux with help of fluxmeter. Ideal 6-8 µw/cm2/nm.
iii. A Plexiglas shield should be used to cover the tube
lights, if the unit is locally made.
31. iv. Baby is placed naked 45 cm away from the tube lights
in a crib or incubator. If using closer, monitor temperature
of the baby.
v. Eyes are covered with eye-patches to prevent damage
to the retina by the bright lights; gonads should also be
covered.
vi. Phototherapy is switched on.
vii. Baby is turned every two hours or after each feed.
viii. Temperature is monitored every two to four hours.
ix. Weight is taken at least once a day.
32. x. More frequent breastfeeding or 10-20% extra fluid is
provided.
xi. Urine frequency is monitored daily.
xii. Serum bilirubin is monitored at least every 12 hours.
xiii. Phototherapy is discontinued if two serum bilirubin
values are < 10 mg/dl.
xiv. Rebound bilirubin is measured 6-8 hours after
stopping phototherapy.
Remember
Baby will appear bleached when under phototherapy and
hence clinical assessment of jaundice is not reliable.
Serum bilirubin must be monitored.
33. Disadvantages of Phototherapy
• Separates baby and parents.
• Eye coverage necessary, which may be disturbing to parents.
• Bronze - baby syndrome if phototherapy given with elevated
conjugated bilirubin.
• Unstable body temperature possible while in open bassinet
(cot) with majority of skin exposed.
• Increased insensible water loss, but less with use of LED light
sources.
34. SIDE EFFECTS OF PHOTOTHERAPY
increased insensible water loss:
Provide more frequent and for longer duration extra
breast feeding.
Loose green stools: weigh often and compensate with
breast milk.
Skin rashes:Harmless, no need to discontinue
phototherapy;
Bronze baby syndrome: occurs if baby has conjugated
hyperbilirubinemia. If so, discontinue phototherapy;
Hypo or hyperthermia: monitor temperature frequently.
35. Exchange transfusion
Baby’ s blood is removed and replaced with transfused blood. Removes
bilirubin and antibodies and corrects anemia. Blood used for exchange
transfusion in neonates with Rh isoimmunization should always have Rh
negative blood group.
Complications include thrombosis, embolus, volume overload or depletion,
metabolic abnormalities, infection, coagulation abnormalities.
36. Phenobarbitone:
It improves hepatic uptake, conjugation and excretion of bilirubin thus
helps in lowering of bilirubin. However its effect takes time.
When used prophylactically in a dose of 5 mg/kg for 3-5 days after birth, it
has shown to effective in babies with hemolytic disease, extravasated blood
and in preterms without any significant side effects.
Intravenous Immunoglobulin ( IVIG )
Can be used in rhesus disease or ABO incompatibility when total bilirubin
levels are rising despite continuous multiple phototherapy or level is near
exchange transfusion level.
38. PROLONGED JAUNDICE
Jaundice present at more than 2 weeks of age for term, 3 weeks for preterm
infants can be considered as prolonged jaundice.
It requires further assessment. First, it needs to be determined if the jaundice is
unconjugated or conjugated.
Unconjugated jaundice causes are:
• Breast milk jaundice – 15% of all breast fed infants are still jaundiced at 2
weeks, gradually decreasing over several weeks
• Hypothyroidism
• Gastrointestinal obstruction, e.g. pyloric stenosis
• Infection
• Liver enzyme disorders.
39. Conjugated jaundice ( > 1.5 mg/dL, 25 micrograms/L)
may be caused by:
• Biliary atresia – uncommon, but important to identify
as delay in surgery adversely affects outcome
• Neonatal hepatitis syndrome.
The infant will pass pale stools (no stercobilinogen) and
dark urine (from bilirubin).
Detailed investigation of infants with conjugated
jaundice is required.
40. Discharge and follow up
In view of the re emergence of kernicterus in otherwise healthy infants,
particularly at 35 – 37 weeks ’ gestation, a follow up assessment is considered
for jaundice depending on their length of stay in the nursery.
• Discharge at < 24 hours, follow - up by 72 hours of life
• Discharge at 24 – 48 hours, follow - up by 96 hours of life
• Discharge at 48 – 72 hours, follow - up by 120 hours of life.
Parents should also be given written and verbal information about jaundice.
Clinical judgment should be used in determining follow-up. Earlier or more
frequent follow-up should be provided for those who have risk factors for
hyperbilirubinemia
41. PREVENTION OF HYPERBILIRUBINEMIA
1. Early and frequent feeding
2. Adequate hydration
3. Administration of Anti-D injection to Rh negative mother
