neonatal jaundice

1. PRESENTER: MUHAMMAD HANIS
NUR AMALINA

2. Case scenario 1
⚫Para 1 at 38w 5d. Blood group: A positive. Pregnancy uneventful
⚫DOB: 27/10/19 at 2338H. CTSH15. G6PD: normal. BW 2.71kg.
CW:2.43kg. Female
⚫Noted on day2 of life prior to discharge, baby jaundice. Was given
follow up at KK. Blood taken at 60 H of life at KK SBV:272 ( IPL: 274,
CPL: 224) with weight loss 10.3% due to poor breastfeeding technique,
thus referred to hospital.
⚫Baby was on intensive phototherapy for 6H

3. ⚫Investigation:
⚪ Hb16.2/ Hct 44.2 TWC 12.6/
Plt 456/ ANC 6
29/10 at KK 30/10 31/10
Urea 9 6
K 4.4 4.2
Na 143 139
Creat 60 43
T.Bili 272 178 125
D.Bili 10 5 6
Direct % 3.7% 2.8% 4.8%
(IPL/CPL) 274/224 291/241 325/275

4. ⚫ Further history:
⚪ Baby has minimal regurgitation 20-30 min post feeding, no vomiting.
⚪ Breast feeding technique poor with duration 60 minutes per session.mother claim sucking
present and good.
⚫ Imp: neonatal jaundice secondary to inadequate feeding
⚫ Upon discharge, breast milk inadequate, but able to EBM and breast feeding
technique acceptable.
⚫ Pt was discharged well on 31/10/19 with Syr. Domperidone 1mg QID and T.
domperidone 10mg TDS (for mother) and TCA to review weight

5. Case scenario 2.
A 10 days old baby boy was referred from KK for neonatal jaundice and weight
loss 11.7%. His t.bil 310. Photo level IPL 359 , CPL309
Further history?
⚫ Para 1 at 39w 1d.Mother’s blood group: B positive. Pregnancy uneventful. SVD
⚫ G6PD normal. CTSH 4. BW:3.68kg. CW 3.25kg. HC 34cm. Lt 52cm.
⚫ 2nd hospitalisation: admitted on D4 of life for NNJ requiring single phototherapy
and discharged on next day.
⚫ Tolerating BFOD every 2 hours, 45minutes each session. Mother claim baby content
after each session. Good sucking. Claim breast milk adequate
⚫ BO yellowish stool (2-3 times/day). PU regularly,yellowish urine ( 8-9 times/day)
⚫ Fever?

6. Examination?
⚫O/E: active, AF soft, not tachypneic, jaundice till abdomen, good pulse
volume, warm peripheries, pink
⚫P/A: soft, not distended. Liver and spleen not palpable.
⚫SBV at KK: 241- 265- 287- 310
⚫Differential Diagnosis?

7. Investigation?
⚫20/11/19:
⚪ Hb 16.7/ Hct 46.9/ TWC 14.9/Plt
616/ ANC 5.6 /CRP 0.6
⚫21/11/19:
⚪ T4: 28, TSH 6.4
⚪ Ammonia 49 / lactate 2.8
⚫UFEME: leu 2+/ nitrite
neg
⚫Urine C+S: no growth
20/11 21/11 22/11 23/11 24/11 25/11
Urea 1.9 1.8
K 5.7 5.2
Na 137 140
Creat 35 40
Ca 2.9
PO4 2.17
Mg 0.79
TP 71 65
Alb 39 37
T.Bili 361 317 234 244 247 209
D.Bili 10 35 22 11 15 16
Direct % 2.7% 11% 9.4% 4.5% 6% 7.6%
(IPL/CPL) 359/309
ET 428
ALP 40 222 200 173
ALT 46 45 39 29

8. ⚫Futher history:
⚪ Mother do EBM post feeding ( 2oz) and threw away
⚫Imp:
1. severe jaundice
2. prolonged jaudice
3.Weight loss secondary inadequate calorie intake

9. Case scenario 3
⚫Para 1 at 38w 3d.Mother’s blood group: AB positive. SVD
⚫ANC:
⚫ Teenage pregnancy
⚫ late booker
⚫Baby boy .G6PD normal. CTSH 4. BW:2.88kg. CW 3.25kg. HC 34cm.
Lt 52cm.
⚫3rd hospitalisation:
⚫ 1) H/o NNJ at D5 of life, admitted 3 days. Highest SBV requiring intensive
phototherapy for a day.
⚫ 2) H/o admission at D12 oflife for 3 days for idiopathic jaundice. weight upon
discharge: 2.6kg

10. ⚫ Baby was referred from KK on D25
of life. Noted SBV 356 ( IPL: 358/
CPL: 308)
⚫ Tolerating BFOD every 2 hours,
30minutes each session. Mother
claim baby content after each
session.
⚫ BO yellowish stool (7-8
times/day). PU regularly,yellowish
urine , not reducing in amount.
⚫ Baby active as usual. Mother
claimed no traditional
medication/Food given.
⚫ CW: 3.125kg ( weight gain 50g/d
since discharge)
⚫ O/E: no significant
findingsFurther history:
⚪ Father and paternal siblings have
G6PD deficiency
⚪ Both parents negative for thalassemia
screening
⚪ No h/0 neonatal death in family
⚪ imp: rebound prolonged jaundice for
investigation

11. 24/7 25/7 27/7 29/7 31/7
HB 13.2 12.6 10.7 10.2
HCT 36.5 35.1 29.1 28.3
TWC 7.1 7.6 8.3 7.0
PLT 369 358 375 382
ANC 3 1 1.3 1.08
Urea 2.4 1.3
K 5.4 5.3
Na 140 139
Creat 42 42
TP 50
Alb 31
T.Bili 302 290 252 211 157
D.Bili 50 39 29 20 19
Direct % 16% 13% 11.5% 9.5% 12%
⚫ CRP 0.3/ ammonia 47
⚫ Lactate 2.6- 3.5- 3.7- 1.9
⚫ LDH 335 -310-301-296
⚫ Reticulocyte 1.2%
⚫ Urine reducing sugar: negative
⚫ PBF: occasional spherocytes seen
TRO recent hemolysis
⚫ Infective screening : non reactive
⚫ UFEME: negative
⚫ Urine C+S: mixed growth with 2
types of gram positive cocci abd 1
type gram negative rod
⚫ Blood group : AB positive. Coombs
test negative

12. ⚫Imp:
⚪ Unconjugated hyperbilirubinemia
⯍ Parents not keen for Gilbert syndrome screening d/t financial issue
⚪ Treat as UTI
⚫Subsequently, pt was discharged well and given TCA to review IEM
result

13. Outline
⚫Introduction
⚫Pathophysiology
⚫Risk Factor And Classification Of Jaundice
⚫Causes Of Jaundice
⚫History Taking
⚫Physical Examination
⚫Investigations
⚫Management

14. INTRODUCTION
⚫ Jaundice is the yellow discoloration of
skin, sclerae, and other tissues caused
by the deposition of bilirubin.
⚫ Jaundice is clinically detectable when
serum bilirubin more than 85ʮmol/L
(5mg/dL)

15. Why does newborn more prone to jaundice?
High hemoglobin mass at birth
Shorter fetal hemoglobin life
span
Low enzyme Glucuronyltransferase activity
(reach adult level by 14 days regardless of gestation)
Low concentration of ligandin Y protein
(carries unconjugated bilirubin to the smooth
endoplasmic reticulum) – increase to adult level by
5-10 days of age
Excessive bilirubin
production
Poor bilirubin
clearance
Liver immaturity
.

16. Pathophysiology : BILIRUBIN METABOLISM

19. Risk factors of severe NNJ
⚫ prematurity
⚫ low birth weight
⚫ jaundice in the first 24 hours of life
⚫ mother with Blood Group O or Rhesus Negative
⚫ G6PD deficiency
⚫ rapid rise of total serum bilirubin
⚫ sepsis
⚫ lactation failure in exclusive breastfeeding
⚫ high predischarge bilirubin level
⚫ cephalhaematoma or bruises
⚫ babies of diabetic mothers
⚫ family history of severe NNJ in siblings
.

20. CLASSIFICATION OF JAUNDICE
UNCONJUGATED / INDIRECT
HYPERBILIRUBINEMIA
CONJUGATED / DIRECT
HYPERBILIRUBINEMIA
Hemolysis present Hemolysis absent Bile duct obstruction
Blood group incompatibility Physiologic jaundice Biliary atresia
ABO incompatibility Breast milk jaundice Choledochal cyst
Rhesus incompatibility Internal haemorrhage Sclerosing cholangitis
RBC enzyme defect Polycythemia Neonatal hepatitis
G6PD deficiency Hypothyroidism Inborn errors of metabolism
Pyruvate kinase deficiency Mutations of glucoronyl
transferase enzyme
Alagille syndrome (arteriohepatic dysplasia)
RBC membrane disorder Criggler-Najjar syndrome Alpha 1 antitrypsin deficiency
Spherocytosis Gilbert’s disease
Ovalocytosis
Haemoglobinopathy
Thalassemia

21. Time frame for jaundice
DAY 1 DAY 7 DAY14(TERM)/DAY21(PRETERM)

22. CAUSES OF JAUNDICE
< 24 HOURS OF AGE 24 HOURS - 2 WEEKS OF AGE > 2 WEEKS OF AGE
HAEMOLYTIC DISORDERS • Physiological jaundice
• Breast milk jaundice
• Infection: e.g. UTI
• Haemolytic disorders
• Bruising
• Polycythemia
• Crigler-Najjar syndrome
UNCONJUGATED
• Rhesus incompatibility
• ABO incompatibility
• G6PD deficiency
• Spherocytosis
• Pyruvate kinase deficiency
• Septicaemia
• Breast milk jaundice
• Hypothyroidism
• Haemolytic
anaemia,G6PD/spherocytosi
s
• Pyloric stenosis
• Galactosemia and Gilbert
CONGENITAL INFECTIONS CONJUGATED
• Toxoplasmosis
• CMV
• HSV
• Rubella
• Bile duct obstruction
• Biliary atresia
• Choledochal cyst
• Sclerosing cholangitis
• Neonatal hepatitis
• TORCHES

23. 1. Age of onset
2. Age of gestation
3. Associated symptoms of jaundice
4. Birth history
5. Feeding history
6. Drug and allergy history
7. Family history
HISTORY TAKING ON NEONATAL JAUNDICE

24. ⚫Preterm (<37 weeks)
⚫Term (>37 weeks)
⚫ The incidence of hyperbilirubinaemia increases with
decreasing gestational age.
⚫ Preterm infants are more susceptible to damage from
raised bilirubin.
AGE OF GESTATION

25. ASSOCIATED SYMPTOMS OF JAUNDICE
•General symptoms
• Yellow skin
• Yellow eye
• Sleepiness
• Decrease in activity
• Difficulty in feeding
• Vomiting
•Intestinal obstruction
•Infection
• Fever
• Rashes
Biliary tract obstruction
• Brown dark urine
• Pale stool
Kernicterus
• Irritabilty
• Fits
• Coma
• Abnormal posture
Hypothyroidism
• Reduced activity
History of falls / trauma

26. BIRTH HISTORY
• ANTENATAL HISTORY
• Mother’s blood group
• Rhesus
isoimmunization
• Intrauterine infection :
TORCHES
• GDM, PIH
• Polycythemia
• INTRAPARTUM
HISTORY
• Birth trauma
• Method of delivery
Instrumental delivery
(forceps /
Ventousse)
• POSTPARTUM HISTORY
• Birth weight
• Loss of weight in the
following days
• APGAR / spontaneous cry
• Asphyxia / HIE / Liver
infarction
• NICU admission
• Neonatal jaundice
• Phototherapy given
• G6PD status
• Cord TSH result

27. • Breast milk jaundice
• (first 4-7 days of life in a
breastfed newborn)
• Contents of breast milk inhibiting
conjugating enzyme in liver
• Breast feeding jaundice
• (first 3 days of life in a
breastfed newborn)
• Insufficient intake of breast milk -
dehydration
FEEDING HISTORY

28. • Drug taken by mother during breastfeeding?
• Any traditional medication taken?
• Any medication taken by baby?
• Any known allergy?
DRUG AND ALLERGY HISTORY

29. • Hemolytic disease
• Previous infants with
• neonatal jaundice
• kernicterus
• G6PD deficiency
FAMILY HISTORY

30. PHYSICAL EXAMINATION
⚫ General condition:
⚫ weight, hydration status, sign of sepsis
⚫ signs of acute bilirubin encephalopathy
(ABE), should be assessed fo all babies with
severe NNJ
⚫ Severity of jaundice
⚫ Sign of kernicterus:
⚫ lethargy, hypotonia, seizure,
opisthotonus,retrocollis, high pitch cry
⚫ Pallor, plethora, SAH, cephalhaematoma
⚫ Sign of intra-uterine infection: petechiea,
hepatospelnomegaly

32. Cephalocaudal progression
FACE > NECK > CHEST > ABDOMEN
> LIMBS
⚫ Visual assessment, Kramer’s rule
⚫ Transcutaneous bilirubinometer- if
Tcb level > 200umol/l, TSB should
be obtained. Not to be used for
patient on phototherapy
⚫ Total serum bilirubin
Method of detecting jaundice

33. INVESTIGATIONS
1. SBV on admission
2. SBV monitoring: if CPL, SBV cm; if IPL / near ET level, SBV 6 hourly
3. If mother’s blood group is O+ve / Rhesus –ve: ABO Coombs
In babies with severe hyperbilirubinaemia, early-onset
neonatal jaundice (<24 hours) or rapid rise of TSB (>8.5
µmol/L/h)
1. FBC, Retic count +/- peripheral blood picture
2. RP if significant weight loss
3. If prolonged jaundice: full LFT, TFT, UFEME, Urine C&S
4. Septic workup: Blood C&S, CRP (if infection is suspected)
5. G6PD screening (if not done)

34. Imaging studies
⚫Ultrasound
⚪ Ultrasound of the liver and bile duct in infants with
laboratory or clinical signs of cholestatic disease

35. Indications for referral to hospital
• Jaundice within 24 hours of life
• Jaundice below umbilicus (200-250 µmol/L)
• Jaundice extending to soles of feet (urgent referral – sign of severe NNJ)
• Family history of significant haemolytic disease or kernicterus
• Any unwell infant with jaundice
• Prolonged jaundice of >14 days
• Conjugated hyperbilirubinemia

36. Treatment
Phototherapy
• Mainstay of treatment in NNJ.
• Phototherapy should be commenced when
total serum bilirubin reaches the
phototherapy threshold for neonatal
jaundice.
• Conventional phototherapy: minimum
irradiance of 15uW/cm2/nm.
• Intensive phototherapy: minimum
irradiance of 30uw/cm2/nm

37. •position the light source - 35-50cm from top surface of the infant
expose infant adequately-cover eyes
monitor serum bilirubin levels as indicated
monitor infant’s temperature 4 hourly to avoid chilling or overheating
ensure adequate hydration and good urine output. adjust fluid(oral)
accordingly.
Routine fluid supplementation is not required with good temperature homeostasis
discontinue phototherapy when serum bilirubin is below phototherapy level

40. Exchange Transfusion
⚫ Indication
⚪ lower serum bilirubin level and reduce the risk of brain damage associated with
kernicterus
⚫ Volume to be exchanged is 2x the infant’s total blood volume (2x80mls/kg)
⚫ Use Fresh Whole Blood preferably < 5 days old
⚫ Connect baby to a cardiac monitor
⚫ Cannulate the umbilical vein
⚫ Aliquot for removal and replacement – 5-6 mls/ kg (Not more than 5-8% of blood volume)
⚫ Maximum volume per cycle - 20 mls for term infants, ≤ 5 ml/kg for ill or preterm infants
⚫ Rate of exchange: 3 -4 minutes per cycle (1 minute ‘out’, 1 minute ‘in’, 1-2 minute ‘pause’
excluding time to discard blood and draw from blood bag)

42. Measures to prevent severe neonatal jaundice
• promote successful breastfeeding (at least 8-10 times/24hours)
• observe infants with G6PD deficiency, for at least 5days if not jaundice and
longer if moderate jaundice
• mother with blood group O and with a sibling who had severe neonatal
jaundice - observe the infant for at least the first 24 hours of life
• infants with hemolytic disease, if phototherapy is initiated early and
discontinued before the infants is 3-4 days old , monitor for rebound
jaundice and adequacy of breast feeding within the next 24-48hours

43. Follow up
• All infants discharged <48hours after birth should be seen within 2-3 days of
discharge
• Infants with risk factors for severe neontal jaundice , early follow up to detect
rebound jaundice after discharge
• Infants with serum bilirubin >20mg/dl and those require exchange transfusion
should be followed for neurodevelopment outcome
• Do a hearing assessment(using BAEP) at 0-3months of corrected age
• Brainstem auditory evoked potential (BAEP)

44. References
1. Malaysian Paediatric Protocol 4th edition.
2. Management of Neonatal Jaundice (2nd edition), Clinical Practice Guideline
Malaysia.
3. Ullah, S., Rahman, K., & Hedayati, M. (2016). Hyperbilirubinemia in Neonates:
Types, Causes, Clinical Examinations, Preventive Measures and Treatments: A
Narrative Review Article. Iranian journal of public health, 45(5), 558–568.
4. Kramer LI. Advancement of Dermal Icterus in the Jaundiced Newborn. Amer J
Dis Child. 1969; 118: 454-458.