jaundice

1. NEONATAL JAUNDICE
Dr V.Vijayakanth

2. Teaching Aids: NNF NJ-
Neonatal Jaundice

3. Facts & figures
 Commonest abnormal physical finding during I week of life
 > 2/3 of NBBs develop clinical jaundice
 Visible form of bilirubinemia
– Adult sclera >2mg / dl
– Newborn skin >5 mg / dl
 Occurrence - 25 – 50% of term, 80% of preterm NBBBs
 Yellow discoloration –
 First evident on skin of face, naso-labial folds and tip of nose
 Masked by physiological plethora
 Assess by blanching
 Assess in good daylight – No yellow light, clothes or curtains

4. Clinical assessment of jaundice
 With increase in jaundice – Cephalo-pedal progression of
yellow discoloration of skin -
Area of body Bilirubin levels
mg/dl
Face 4-8
Upper trunk 5-12
Lower trunk & thighs 8 - 16
Arms & lower legs 11 - 18
Palms & soles > 15
 Imp! – Screen all NBBs x BD in good day light

5. Bilirubin turnover

6. Sources of Bilirubin
 Haem containing proteins
RBC Hb – Major source. 1 gm Hb  34 mg
of Bilirubin
- Haem from ineffective erythropoiesis in bone
marrow
- Other haem containing proteins – myoglobin,
cytochromes, catalase, peroxidase
- Free haem

7. Bilirubin
turnover in
Newborn
Hb  Haem + Globin
Other sources
BILIRUBIN
UCB binds to S albumin
Dissociates from albumin
UDPG - T
Bil monoglucoronide +
Bil Diglucoronide
Water sol Bil
Binds to cytoplasmic
Ligandin (Y protein)
Excreted into bile canaliculi
Enters Gut
Excreted in stool
Biliverdin + CO + Fe
Bilirubin Reductase
Haem oxygenase
Beta Glucoronidase
UCB
Production
Transport
Uptake
Excretion
Conjugation

8. Physiological handicaps causing
increased Bilirubin turnover
1. Increased production of bilirubin
 Physiological Polycythemia
 Shorter life span of HbF (90 days)
 1ml/kg (approx 1% ) of blood hemolyse everyday
 0.15 gm/ kg of Hb released everyday
 1 gm Hb yields 35 mg of bilirubin
 Hence, a 3 kg infant produces 15 mg bil/ day from Hb sources
+ 1 mg/kg from non Hb sources
 Thus, daily load to the liver – 20 mg bil
2. Defective uptake from plasma
 Non availability of albumin binding sites

9. Physiological handicaps…
3. Defective conjugation
 Transient deficiency of Y & Z acceptor proteins
4. Reduced hepatic clearance
 Reduced UDPG enzymes
 >ed unconjugated bil in early days of life in preterms
5. Enhanced enterohepatic circulation
 100 – 200 mg of bil in gut as 1 mg/gm of meconium
 Reduced gut motility & poor evacuation
 Paucity of bacterial flora in gut of NBB
 Over activity of intestinal glucoronidase enzyme
 Conj Bil rapidly deconjugated and recirculated through blood to liver
for reconjugation

10. Bilirubin load causing jaundice in
Newborn
>ed RBC vol & <ed RBC survival
>ed Bil monoglucoronide
<ed Bil Diglucoronide
UCB
Production
Transport
Uptake
Excretion
Conjugation
>ed Ineffective erythropoiesis & >ed Heam
turnover
Non availability of Albumin
binding sites
Defective conjugation
<ed LIigandin
Decreased excretion
<ed gut motility
Poor evacuation
>>ed beta glucoronidase, <ed
intestinal bacteria
>ed BILIRUBIN load
Defective uptake from plasma
>ed Entero-hepatic circulation

11. Causes of jaundice

12. Within 24 hours of birth
 Hemolytic disease of newborn - due to feto-maternal
group incompatibility (Rh, ABO, other minor blood
group systems)
 Intra-uterine infections (TORCH)
 Deficiency of red cell enzymes – G6 PD, pyruvate
kinase, heokinase, phospho-glucose isomerase, unstable
Hbs
 Admn of drugs in excess – Vit K, salycilates,
sulfisoxazole to mother
 Hereditary spherocytosis
 Criggler Najjar syndrome
 Lucey Driscoll syndrome
 Homozygous alpha thalassemia

13. Between 24 – 72 hours of age
 Physiological jaundice
 May be aggravated/ prolonged by –
Immaturity, birth asphyxia, acidosis, hypothermia,
hypoglycemia, drugs, cephalhematoma, hge’/
bruising, Polycythemia, high altitude, cretinism,
breast feeding, infections
Mild hemolytic states – Feto maternal blood gp
incompatibility, spherocytosis, deficiency of cell
enzymes

14. After 72 hrs of age ( and within
first 2 weeks)
 Septicemia
 Neonatal hepatitis
 Extra hepatic biliary atresia
 Breast milk jaundice
 Metabolic diseases – Galactosemia, tyrosinemia,
fructosemia, organic acidemia, cyctic fibrosis,
alpha 1 anti trypsin deficiency
 Hypertrophic pyloric stenosis & intestinal
obstruction

15. Drugs causing increase in
bilirubin
Drugs Nature of action
Vit K in larg doses Hemolysis
Vit K and kanamycin Block Y acceptor protein
Novobiocin, Moxalactam, Gentamycin,
Kanamycin, Chloramphenicol
Compete for Glucoronyl
transferase
Salicylates, long acting sulphonamides,
sodium benzoate, furosamide,
indomethacin, radiographic contract media
Block bilirubin binding sites in
albumin
Oxytocin (induced labour) Hyponatremia & hypo
osmolality
Spinal block for mother using Bupivacaine

16. Risk factors for 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. Common causes in Sri Lanka
 Physiological
 Blood group incompatibility
 Intrauterine and postnatal infections
 G-6PD deficiency
 Bruising and cephalhematoma
 Breast milk jaundice

18. Jaundice – Physiological &
Pathological

19. Physiological jaundice
 Appears between 30 – 72 hrs of age in term babies (earlier in
preterms)
 Maximum intensity by 4th-5th day in term & 7th day in preterm
 Serum level less than 15 mg / dl
 Disappears by 10 days of life (reaches 15 days in preterms)
 Disappears without any treatment
 Note:
 Baby should, however, be watched for worsening jaundice
 Alert in preterms…danger of brain damage!

20.  Features of physiological jaundice (all of
the following
 Jaundice that first appears between 24-72 hours of
age
 Maximum intensity is seen on 4-5th day in term
and 7th day in preterm neonates
 Does not exceed 15 mg/dl (255μmol/l)
 Clinically undetectable after 14 days
 Physiological jaundice is a diagnosis by exclusion. No treatment is
required but baby should be observed closely for signs of worsening
jaundice

21. Pathological jaundice
 In 5% of newborns
 Appears within 24 hours of age
 Serum bilirubin > 15 mg / dl after 24h
 Jaundice persisting after 14 days
 Stool clay / white colored and urine staining clothes yellow
 Direct bilirubin> 2 mg / dl
 Total serum bilirubin (TSB) increasing by > 5mg/dl/day(85
μmol/l/day) or 0.5 g/dl/hr (8.5μmol/l/hr)

22. Dangers of hyperbilirubinemia
 Unconjugated hyperbilirubinemia  Bil encephalopathy/
Kernicterus
 C/F – Refusal of feeds, shrill cry, setting sun sign,
convulsions, retrocollis and opisthotonus
- Sluggish Moro’s response, lethsrgy, poor feeding
- Preterms – Non specific. Die due to apneic attacks
- Infancy – Athetoid cerebral palsy, choreo-athetosis,
brownish staining of teeth, dental dysplasia, deafness,
paralysis of upward gaze, intellectual retardation &
learning disabilities

23. Pathogenesis of kernicterus
 Related to –
Unconjugated bilirubin levels
Gestational maturity of infant
Integrity of blood-brain barrier
 Biochemical determinants –
Bilirubin protein ratio – 3.5 or more
HBABA (hydroxybenzene azo benzoic acid) dye
binding capacity - < 50%
Salicylate saturation index – 8 or moreRBC biuding
of bilirubin - >4 mg%

24. Kernicterus

25. Assessment

26. Approach to a jaundiced baby
Ask 4 questions -
 What is the birth weight?
 What is the gestation?
 What is the postnatal age in hours?
 Is the jaundice physiological or pathological?
If jaundice is physiological and baby is well – only
observe
If deep jaundice – Assess for bil toxicity
(kernicterus)

27. Indication for lab investigations
(In high risk infants)
 H/O Jaundice, Exchange Blood transfusion /
Kernicterus in previous sibling
 Mother – O group or Rh –ve
 Jaundice – Within 24 hrs or after 72 hrs
 Trunk distinctly yellow stained
 Sick jaundiced baby
 Jaundice persisting > 2 weeks
 Yellow coloured urine or clay coloured stools

28. Workup
 Maternal & perinatal history
 Physical examination
 Laboratory tests (must in all)
 Total & direct bilirubin (Total : 0.3 to 1.9 mg % , Direct : 0 to 0.3
mg %)
 Bil: protein ratio (< 3.4)
 Blood group and Rh for mother and baby
 Blood - Hematocrit, retic count and peripheral smear, Sepsis
screen, Carboxy Hb
 Liver function - Vanden Bergh test
 Thyroid function
 TORCH titers, liver scan when conjugated hyperbilirubinemia
 Tests for –
 Pulmonary excretion rate of CO, OR
 End tidal CO (Etco) breath level

29. Assessment of severity of
jaundice
 Assess in natural daylight for cephalo-
pedal progression
 (Unreliable after phototherapy)
 Use of ‘Icterometer’
 Transcutaneous bilimeter
 Bilimeter with microcentrifuge

31. Management

32. Management of jaundice
 A medical emergency
 Aim –
Keep S bilirubin at a safe level and prevent bil
toxicity
Prevent brain damage
 Methods –
Preventive and supportive measures
 Reduction of bilirubin levels – Phototherapy,
Exchange transfusion (-most effective and reliable
method), drugs

33. Preventive and supportive
measures
 Prevention of Rh isoimmunization
 Withhold drugs that aggravate jaundice or
block bilirubin binding sites in albumin
 Prevent perinatal distress factors
 Avoid phenolic detergents in nursery

34.  Adequate feeding and hydration
 Aspiration of cephalhematoma (bil > 18
mg%)
 Treatment of sepsis and hepatitis
 Phenobarbitone
 Clofibrate – Enhances glucoronyl
transferase

36. Measures to reduce Serum
Bilirubin
 Phototherapy
 Drugs blocking entero-hepatic circulation
of bilirubin
 Exchange transfusion
 Sunlight –NO!

37. Measures to reduce S Bilirubin -
Phototherapy
 Safe and effective
 Bil absorbs light maximally at 420 –
460 nm
 Causes photo-oxidation & photo-
isomerization of bilirubin
 Enhances hepatic exertion of
unconjugated bil into the intestinal
lumen
 Single & double surface system

38. Phototherapy equipment
 White light tubes 6-8*/ 4 blue light
tubes
 Cradle or incubator
 Eye shades
*May use 150 W halogen bulb

39. Babies under phototherapy
Baby under conventional
phototherapy
Baby under triple unit intense
phototherapy

40. Phototherapy
 Safe and effective
 Bil absorbs light maximally at 420 – 460 nm
 Causes photo-oxidation & photo-isomerization of bilirubin
 Enhances hepatic exertion of unconj bil into the intestinal lumen
 Single & double surface system
 6 - 8 daylight tubes or 4 blue/ white tubes mounted on a stand with
grounded electrical outlets.
 Change tubes every 1000 hours or after 3 months of use
 Alternate - 150 watt halogen bulb (life 1000 hours) OR Blue CFL
lamps - change every 3000 h..
 Maintain flux at 6-8 mw/cm2/nm with help of fluxmeter.
 Have Plexiglas shield to cover the tube lights.
 Nurse in cradle or incubator

41. Phototherapy
 Perform hand wash
 Place baby naked 45 cm away from the tube lights in a crib or incubator
 Fix eye shades - to prevent damage to the retina. Also cover gonads
 Keep baby at least 45 cm from lights, if using closer monitor temperature of
baby
 Start phototherapy
 Frequent extra breast feeding every 2 hourly
 Turn baby every two hours or after each feed (in single surface)
 Monitor – Temp - 2 to 4 hourly, wt -daily, urine frequency, bilirubin - 12
hrly
 More frequent breastfeeding or 10-20% extra fluid is provided.
 Discontinue phototherapy - if two serum bilirubin values are < 10 mg/dl.
 Measure rebound bilirubin 6-8 hours after stopping phototherapy.

42.  Turn baby every two hours or after each feed (in single
surface)
 Monitor temperature of the baby x 2 – 4 hrly..
 Monitor daily - Urine frequency and body wt
 More frequent breastfeeding or 10-20% extra fluid is
provided.
 Monitor Serum bilirubin at least every 12 hours
 Measure rebound bilirubin 6-8 hours after stopping
phototherapy.
Remember - Baby appears bleached when under phototherapy. Hence
clinical assessment of jaundice not reliable. Monitor S bilirubin.

43.  Repeat serum bilirubin measurement 4–6 hours after initiating
phototherapy.
 Repeat levels 4-6 hourly if serum bilirubin is rising or is not falling
while under phototherapy.
 Repeat serum bilirubin measurement every 12-24 hours when the
serum bilirubin level is stable or falling.
 • Stop phototherapy once bilirubin levels are below the phototherapy
level by 2 -3 mg/dl (35 - 50μmol/l) as per postnatal age.
 • In case of haemolytic jaundice, check bilirubin levels after 12
hours of stopping phototherapy to check for rebound increase.

44. Side effects of phototherapy
 Increased insensible water loss
 Loose stools
 Skin rash
 Bronze baby syndrome
 Hyperthermia
 Upsets maternal baby interaction
 May result in hypocalcemia

46. Drugs blocking entero-hepatic
circulation of bilirubin
Drug Action
Charcoal, Agar, Bind unconj bilirubin in gut and prevents entero-
hepatic circulation
Cholestyramine Enhances fecal exrcretion of bilirubin by binding
unconj bil and bile salts
Orotic acid Used to conjugate bilirubin
Tin-mesoporphyrin
(SnMP)
Inhibit heam oxygenase & reduce productin of
bilirubin
Albumin infusion Improves bilirubin binding capacity

47. Exchange transfusion
 Most effective and reliable method to
reduce serum bilirubin.
 Anticipation and early referral to a higher
centre is important
 Indications –
 Cord Hb 10 gm% or less
 Cord bilirubin 5 mg% or more
 Unconj S bil 10 mg% within 24 hrs or 15
mg% within 48 hrs or rate of rise of 0.5 mg%
per hr

48. Choice of blood for exchange
blood transfusion
 ABO incompatibility
– Use O cells of same Rh type, ideal - O cells
suspended in AB plasma.
 Rh isoimmunization
– In emergency 0 -ve blood. Ideal 0 -ve suspended in
AB plasma or baby's blood group but Rh –ve blood
also
 Other situations
– Baby's blood group

49. Indications for Exchange
Transfusion
 Hyperbilirubinaemia (Rhesus/ABO
incompatibility) to prevent kernicterus
 Anaemia/ Hydrops
 Polycythemia ie. partial exchange
 Rare conditions
 Hyperkalaemia
 Drug toxicity/overdose
 Disseminated intravascular coagulation
 Maternal AntibodiesEY

50. The exchange equipment
The volume of blood required - .
1. Single blood volume exchange for anaemia:
– Term infant – 80 -100mls /kg
– Preterm infant – 100mls/kg
– Volume exchanged (ml) = Wt (kg) x Blood Volume x
(Hb desired – Hb initial)
2. Double volume exchange for jaundice: (Approx 2 x 85
mls/kg)
- Term infant – 200 -250 mls/kg or 80 – 85 mls/kg x
2/3
- Preterm infant – 300 mls/kg or 100 – 120 mls/kg x 2/3

51. Procedure
 'PUSH-PULL METHOD’ via the umbilical vein.
- Serial withdrawal and injection of aliquots (5-20 mls)
– 1 mt for each cycle. Takes 60 – 120 minutes.
- Used when arterial arterial access is a problem.
 ‘ISOVOLUMETRIC METHOD’ - slow removal of
aliquots (10mls usually) from an artery (central or peripheral)
and simultaneous infusion into a vein (central or peripheral).
- preferred method
- Does not cause wide fluctuations of blood volume and
pressure.
- Takes 60 – 90 minutes

52. First out specimen tested for -
 Haemoglobin, film, PCV
 Group, Rhesus, Direct Coomb's test
 PGL
 Urea and electrolytes, calcium, SBR, total and
conjugated
 Blood gas
 Coagulations profile
 Newborn screening test
 Hold samples for other tests as indicated, eg. G6PD
deficiency, Viral infection, hereditary
 spherocytosis, metabolic studies.

53. Set up for Push Pull method
 UAC tray and catheters
 Sterile drapes
 Blood administration set
 3-way taps X 2 (white blood in, red for blood out to waste)
 Exchange transfusion recording sheet
 Blood warmer with appropriate coil
 Extension tubing, long - must be wide bore
 Drainage connecting tube
 5ml, 10ml, and 20ml syringes depending on size of aliquots to be
used
 Waste bag
 Calcium gluconate 10% ampoules
 Heparin ampoules1000 IU/ml or heparinised NaCl 0.9% 50 ml
syringe

54. Exchange transfusion

55. Hydrops fetalis

56. THANK YOU