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Neonatal Jaundice

1
Learning Objectives
By the end of the lecture the Class is able to:
•Define neonatal Jaundice.
•Differentiate between physiological and pathological
jaundice.
•State causes of neonatal jaundice.
•Discuss the pathophysiology of neonatal jaundice.
•Describe the complications of neonatal jaundice.
•List the three elements of therapeutic management.
•Design a nursing care plan for the baby with neonatal
jaundice.
2
Anatomy & Physiology

3
Definition
• Yellow discoloration of the skin and the
mucosa due to accumulation of excess of
bilirubin in the tissue and plasma in neonates.
(more than 7mg/dl).
30-50 % of term
newborn
And more of
preterm newborns.
4
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
5
Causes

Physiological

Pathological

6
Pathophysiology

7
Physiological Causes
1. Increased red cell volume & increased red
cell destruction.
2.Decreased conjugation of bilirubin d/t
decreased UDPG-T activity.
3.Increased enterohepatic circulation d/t
decreased gut motility.
4.Decreased hepatic excretion of bilirubin.
5.Decreased liver cell uptake of bilirubin d/t
decreased ligandin.
8
Pathological Causes
1.
2.
3.
4.
5.
6.
7.

Excessive Red cell hemolysis.
Defective conjugation of bilirubin.
Breast milk jaundice.
Metabolic and endocrine disorders.
Increased enterohepatic circulation.
Substances and disorders that affect binding.
Miscellaneous.
9
Assessment And Diagnosis

10
HISTORY
onset / duration
pain
nausea & vomiting
loss of weight
itching
color of stool
color of urine
past history
ttt &family history
11
EXAMINATION
 color of skin
 severity of jaundice
 anemia
 liver
 spleen
 gall bladder
 ascites
12
Diagnosis

Lab Studies
• Total conjugated &
unconjugated
bilirubin.
• Complete hemogram
• Blood group status.
• Direct coombs test.
• Serum albumin
• Other lab tests

Urine

Radiology
& USG

Hb electrophoresis

Osmotic Fragility
tests
Thyroid and LFTs
G6PD screening.
13
Signs And Symptoms
Symptoms may include:
•Yellow coloring of the
baby's skin (usually
beginning on the face
and moving down the
body)
•Poor feeding or
lethargy

14
Complications
• Kernicterus
Most Important, Often Fatal.

15
Medical Management
Phototherapy

Phenobarbital
Therapy

Metalloporphyrins

Exchange
Transfusion
16
Phototherapy
• When bilirubin > 12 %
• Discontinued when
level fallen > 2mg/dl of
previous.

17
Babies under phototherapy

Baby under conventional
phototherapy

Baby under triple unit intense
18
phototherapy
TransBilirubin

CisBilirubinisomer + Lumibilirubin
By Photoisomerisation

Excreted in the bile & Urine without
Conjugation.

19
Technique

6-8 daylight tubes are mounted on a stand and
all electrical outlets are well grounded.

20
Baby is placed naked 45 cm away from the tube lights in a
crib or incubator.
Eyes are covered with eye-patches to prevent damage to
the retina by the bright lights; gonads should also be
covered.
Phototherapy is switched on.

21
Baby is turned every two hours or after each feed.
Temperature is monitored every two to four hours.

Weight is taken at least once a day.
More frequent breastfeeding.

Urine frequency is monitored daily.
Serum bilirubin is monitored at least every 12 hours.

Phototherapy is discontinued if two serum bilirubin
values are < 10 mg/dl.

22
Contraindication :
Liver disease or obstructive jaundice.

Complications :
Watery diarrhoea
Skin rashes
Dehydration
Bronze baby syndrome
Retinal damage

23
24
Side effects of phototherapy
•Increased insensible water loss: Frequent 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.
25
Phenobarbital Therapy
ligandin in liver

Induces hepatic enzymes

billirubin conjugation & excretion
Dose: 10mg/kg Day 1 (loading dose)
5-8 mg/kg/day 4 days (maint. dose)

Or to Mother 2 weeks prior delivery.
Dose: 90 mg/day.
26
Metalloporphyrins
bilirubin by inhibiting heme oxygenase

Tin & Zinc are currently used.

27
Exchange transfusion

28
Indications:

Rise of bilirubin >1mg/dl/hour

To improve anemia & CCF
Sr. Bilirubin > 20mg/dl in first 24 hrs
Cord hemoglobin is < 12mg/dl & bilirubin is > 5mg/dl

29
• It is still the most effective and reliable
method to reduce serum bilirubin

30
The procedure involves the incremental removal
of the patient's blood and simultaneous
replacement with fresh donor blood, saline or
plasma.

31
• The patient’s blood is slowly drawn out

• And an equal amount of fresh, prewarmed
blood, plasma or physiologic saline is
transfused.
• The cycle is repeated until a predetermined
volume of blood has been replaced.

32
Risk and Complications
• Cardiac and respiratory disturbances
• Shock due to bleeding or inadequate
replacement of blood
• Infection
• Clot formation
• Rare but severe complications include: air
embolism, portal hypertension and
necrotizing enterocolitis
33
Prevention
• Breastfeeding
–
–
–
–

Should be encouraged for most women
8-12 times/day for 1st several days
Assistance and education
Avoid supplements in non-dehydrated
infants

34
Ongoing assessments for risk of developing
severe hyperbilirubinemia
– Monitor at least every 8-12 hours
– Don’t rely on clinical exam
– Blood testing
• Prenatal : ABO & Rh type, antibody
• Infant cord blood

35
Nursing Management

36
Nursing considerations of Hyperbilirubinemia

• Assessment:
 observing for evidence of
jaundice at regular intervals.
 Jaundice is common in
the first week of life and
may be missed in dark skinned
babies
NJ - 37

Blanching the tip
of the nose
The goals of planning
• Infant will receive appropriate therapy if
needed to reduce serum bilirubin levels.
o Infant will experience no complications from
therapy.
o Family will receive emotional support.
o Family will be prepared for home
phototherapy (if prescribed).

NJ - 38
39

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Neonatal Jaundice

  • 2. Learning Objectives By the end of the lecture the Class is able to: •Define neonatal Jaundice. •Differentiate between physiological and pathological jaundice. •State causes of neonatal jaundice. •Discuss the pathophysiology of neonatal jaundice. •Describe the complications of neonatal jaundice. •List the three elements of therapeutic management. •Design a nursing care plan for the baby with neonatal jaundice. 2
  • 4. Definition • Yellow discoloration of the skin and the mucosa due to accumulation of excess of bilirubin in the tissue and plasma in neonates. (more than 7mg/dl). 30-50 % of term newborn And more of preterm newborns. 4
  • 5. 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 5
  • 8. Physiological Causes 1. Increased red cell volume & increased red cell destruction. 2.Decreased conjugation of bilirubin d/t decreased UDPG-T activity. 3.Increased enterohepatic circulation d/t decreased gut motility. 4.Decreased hepatic excretion of bilirubin. 5.Decreased liver cell uptake of bilirubin d/t decreased ligandin. 8
  • 9. Pathological Causes 1. 2. 3. 4. 5. 6. 7. Excessive Red cell hemolysis. Defective conjugation of bilirubin. Breast milk jaundice. Metabolic and endocrine disorders. Increased enterohepatic circulation. Substances and disorders that affect binding. Miscellaneous. 9
  • 11. HISTORY onset / duration pain nausea & vomiting loss of weight itching color of stool color of urine past history ttt &family history 11
  • 12. EXAMINATION  color of skin  severity of jaundice  anemia  liver  spleen  gall bladder  ascites 12
  • 13. Diagnosis Lab Studies • Total conjugated & unconjugated bilirubin. • Complete hemogram • Blood group status. • Direct coombs test. • Serum albumin • Other lab tests Urine Radiology & USG Hb electrophoresis Osmotic Fragility tests Thyroid and LFTs G6PD screening. 13
  • 14. Signs And Symptoms Symptoms may include: •Yellow coloring of the baby's skin (usually beginning on the face and moving down the body) •Poor feeding or lethargy 14
  • 17. Phototherapy • When bilirubin > 12 % • Discontinued when level fallen > 2mg/dl of previous. 17
  • 18. Babies under phototherapy Baby under conventional phototherapy Baby under triple unit intense 18 phototherapy
  • 19. TransBilirubin CisBilirubinisomer + Lumibilirubin By Photoisomerisation Excreted in the bile & Urine without Conjugation. 19
  • 20. Technique 6-8 daylight tubes are mounted on a stand and all electrical outlets are well grounded. 20
  • 21. Baby is placed naked 45 cm away from the tube lights in a crib or incubator. Eyes are covered with eye-patches to prevent damage to the retina by the bright lights; gonads should also be covered. Phototherapy is switched on. 21
  • 22. Baby is turned every two hours or after each feed. Temperature is monitored every two to four hours. Weight is taken at least once a day. More frequent breastfeeding. Urine frequency is monitored daily. Serum bilirubin is monitored at least every 12 hours. Phototherapy is discontinued if two serum bilirubin values are < 10 mg/dl. 22
  • 23. Contraindication : Liver disease or obstructive jaundice. Complications : Watery diarrhoea Skin rashes Dehydration Bronze baby syndrome Retinal damage 23
  • 24. 24
  • 25. Side effects of phototherapy •Increased insensible water loss: Frequent 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. 25
  • 26. Phenobarbital Therapy ligandin in liver Induces hepatic enzymes billirubin conjugation & excretion Dose: 10mg/kg Day 1 (loading dose) 5-8 mg/kg/day 4 days (maint. dose) Or to Mother 2 weeks prior delivery. Dose: 90 mg/day. 26
  • 27. Metalloporphyrins bilirubin by inhibiting heme oxygenase Tin & Zinc are currently used. 27
  • 29. Indications: Rise of bilirubin >1mg/dl/hour To improve anemia & CCF Sr. Bilirubin > 20mg/dl in first 24 hrs Cord hemoglobin is < 12mg/dl & bilirubin is > 5mg/dl 29
  • 30. • It is still the most effective and reliable method to reduce serum bilirubin 30
  • 31. The procedure involves the incremental removal of the patient's blood and simultaneous replacement with fresh donor blood, saline or plasma. 31
  • 32. • The patient’s blood is slowly drawn out • And an equal amount of fresh, prewarmed blood, plasma or physiologic saline is transfused. • The cycle is repeated until a predetermined volume of blood has been replaced. 32
  • 33. Risk and Complications • Cardiac and respiratory disturbances • Shock due to bleeding or inadequate replacement of blood • Infection • Clot formation • Rare but severe complications include: air embolism, portal hypertension and necrotizing enterocolitis 33
  • 34. Prevention • Breastfeeding – – – – Should be encouraged for most women 8-12 times/day for 1st several days Assistance and education Avoid supplements in non-dehydrated infants 34
  • 35. Ongoing assessments for risk of developing severe hyperbilirubinemia – Monitor at least every 8-12 hours – Don’t rely on clinical exam – Blood testing • Prenatal : ABO & Rh type, antibody • Infant cord blood 35
  • 37. Nursing considerations of Hyperbilirubinemia • Assessment:  observing for evidence of jaundice at regular intervals.  Jaundice is common in the first week of life and may be missed in dark skinned babies NJ - 37 Blanching the tip of the nose
  • 38. The goals of planning • Infant will receive appropriate therapy if needed to reduce serum bilirubin levels. o Infant will experience no complications from therapy. o Family will receive emotional support. o Family will be prepared for home phototherapy (if prescribed). NJ - 38
  • 39. 39

Editor's Notes

  1. Symptoms may include:Yellow coloring of the baby&apos;s skin (usually beginning on the face and moving down the body)Poor feeding or lethargy