This document provides an overview on approaching and managing a child with jaundice. It begins by defining jaundice as a visible manifestation of increased bilirubin levels. It then discusses the burden of jaundice in newborns, describing how most will experience some jaundice in the first week due to immature bilirubin metabolism. The document outlines how to classify jaundice as physiological or pathological based on clinical signs and bilirubin levels. For pathological jaundice, the main treatment approaches of phototherapy and exchange transfusion are described. The document provides guidance on evaluating the potential causes of jaundice and managing cases based on whether the hyperbilirubinemia is conjugated or
Approach to neonatal jaundice - Simplified
references : Cloherty And Stark's Manual Of Neonatal Care
AIIMS Protocol In Neonatology
Care Of The Newborn – Meherban Singh
Pancreatitis is an inflammatory condition of the pancreas. Two major forms : acute pancreatitis (is reversible) and chronic pancreatitis(is irreversible).
Approach to neonatal jaundice - Simplified
references : Cloherty And Stark's Manual Of Neonatal Care
AIIMS Protocol In Neonatology
Care Of The Newborn – Meherban Singh
Pancreatitis is an inflammatory condition of the pancreas. Two major forms : acute pancreatitis (is reversible) and chronic pancreatitis(is irreversible).
Hyperbilirubinemia didactics at Neonatal Intensive Care Unit
Source: Nelson's Textbook of Pediatrics 19th edition
Most pictures were taken from Google images
Icterus neonatorum presentation for studentsNehaNupur8
Introduction
Definition
Metabolism and excretion of bilirubin
Causes
Symptoms
Types
Physiological jaundice
Pathological jaundice
Breast milk jaundice
Neo natal jaundice is a yellow discoloration of the white part of the eyes and skin in a newborn baby due to high bilirubin level.
Neo natal jaundice becomes apparent at serum bilirubin concentration of 5-7mg / dL.
Shoulder and trunk 8-10mg/dl
Lower body – 10-12mg/dl.
Entire body 12-15 mg /DL
Neonatal jaundice occurs in 60% of term and 80% of preterm babies. Despite Neonatal jaundice is one of the commonest neonatal conditions, there are no national practice guidelines for its management in our country. Lack of uniform guidelines and standard practice parameters for diagnosis and management of neonatal jaundice often leads many babies to develop unnoticed hyperbilirubinemia causing kernicterus and long term poor neurological sequelae. This review after briefly discussing the epidemiology and pathophysiology of neonatal jaundice provides evidence-based pragmatic guidelines for the diagnosis and management of neonatal jaundice in resource-limited countries like Afghanistan
The Indian economy is classified into different sectors to simplify the analysis and understanding of economic activities. For Class 10, it's essential to grasp the sectors of the Indian economy, understand their characteristics, and recognize their importance. This guide will provide detailed notes on the Sectors of the Indian Economy Class 10, using specific long-tail keywords to enhance comprehension.
For more information, visit-www.vavaclasses.com
How to Split Bills in the Odoo 17 POS ModuleCeline George
Bills have a main role in point of sale procedure. It will help to track sales, handling payments and giving receipts to customers. Bill splitting also has an important role in POS. For example, If some friends come together for dinner and if they want to divide the bill then it is possible by POS bill splitting. This slide will show how to split bills in odoo 17 POS.
This is a presentation by Dada Robert in a Your Skill Boost masterclass organised by the Excellence Foundation for South Sudan (EFSS) on Saturday, the 25th and Sunday, the 26th of May 2024.
He discussed the concept of quality improvement, emphasizing its applicability to various aspects of life, including personal, project, and program improvements. He defined quality as doing the right thing at the right time in the right way to achieve the best possible results and discussed the concept of the "gap" between what we know and what we do, and how this gap represents the areas we need to improve. He explained the scientific approach to quality improvement, which involves systematic performance analysis, testing and learning, and implementing change ideas. He also highlighted the importance of client focus and a team approach to quality improvement.
How to Make a Field invisible in Odoo 17Celine George
It is possible to hide or invisible some fields in odoo. Commonly using “invisible” attribute in the field definition to invisible the fields. This slide will show how to make a field invisible in odoo 17.
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
Students, digital devices and success - Andreas Schleicher - 27 May 2024..pptxEduSkills OECD
Andreas Schleicher presents at the OECD webinar ‘Digital devices in schools: detrimental distraction or secret to success?’ on 27 May 2024. The presentation was based on findings from PISA 2022 results and the webinar helped launch the PISA in Focus ‘Managing screen time: How to protect and equip students against distraction’ https://www.oecd-ilibrary.org/education/managing-screen-time_7c225af4-en and the OECD Education Policy Perspective ‘Students, digital devices and success’ can be found here - https://oe.cd/il/5yV
Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
This presentation provides a briefing on how to upload submissions and documents in Google Classroom. It was prepared as part of an orientation for new Sainik School in-service teacher trainees. As a training officer, my goal is to ensure that you are comfortable and proficient with this essential tool for managing assignments and fostering student engagement.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
The French Revolution Class 9 Study Material pdf free download
Approach to a child with jaundice
1. APPROACH TO A CHILD
WITH JAUNDICE
APPROACH TO A CHILD
WITH JAUNDICE
S.BALASANKAR
S.BALASANKAR
2009 MBBS
2009 MBBS
2. JAUNDICE
Jaundice is the visible manifestation of
increased level of bilirubin in the body.
It is not a disease rather a symptom of
diseases.
In adults sclera appears jaundiced when
serum bilirubin exceeds 2 mg/dl.
However it is difficult to see sclera in
newborn due to difficulty in opening eye.
But in new born it is very easy to see
3. BURDEN
Important problem in the 1st week of life.
Almost all neonates (60% Term and 80%
Preterm) will have bilirubin > 5 mg/dl in the
1st week of life and become visibly
jaundiced, vast majority being benign
Some of the term babies (8 to 9%) have
levels exceeding 15 mg/dl in 1st 7 days of
life.
High bilirubin level is toxic to the developing
CNS.(KERNICTERUS; Bilirubin≥25mg/dl)
4. BILIRUBIN
End product of hemoglobin metabolism
that is excreted in bile.
In neonates
-75% : from catabolism of circulating
RBCs
-25% :*from ineffective erythropoiesis
(bone marrow)
*from turnover of heme proteins
&
12. PHYSIOLOGICAL JAUNDICE:
•
In new born babies bilirubin
metabolism is immature which results in the
occurrence of hyperbilirubinemia in the first
few days of life. Also there is increased
bilirubin load on the hepatic cell due to
physiological polycythemia.
13. Immaturity could be at various steps of
bilirubin metabolism like:
Defective uptake from plasma into liver
cell( deficiency of LIGANDIN)
Defective conjugation( UDP-glucoronosyl
transferase: <1% of adult activity during
the first 10 days of life)
Decreased excretion
Increased entero-hepatic circulation
14. Increased Bilirubin production:
Larger circulating red blood cell volume
Shortened RBC lifespan (70-90 days vs 120
days in adult)
Substantial production from other sources
15. Characteristics:
First appears between
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.
16. PATHOLOGICAL JAUNDICE
Presence of any of the following signs
denotes that the jaundice is pathological.
Clinical jaundice detected before 24 hours
of age
Rise in serum total bilirubin by more than 5
mg/dl/ day (>5mg/dl on first day , 10 mg/dl
on second day and 12- 13 mg/dl thereafter
in term babies)
17. 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 nappy yellow
Direct bilirubin >2 mg/dl at any time.
Treatment is required in the
form of phototherapy or exchange blood
transfusion. One should investigate to find the
cause of pathological jaundice.
19. Overproduction Hyperbilirubinemia:
Blood group incompatibilities
Maternal-fetal or feto-fetal transfusions
Non Immune Hemolytic anemias
Structurally Abnormal Red cells
Extra-vascular Hemolysis
20. Blood Group Incompatibilities:
Rh negative mother & Rh positive infant
ABO incompatibilities
Strongly considered if there is jaundice in
the first 24 hours of life
21. Non-Immune Hemolytic Anemias:
1. G6PD Deficiency:
Deficiency-decreased NADPHdecreased reduced Glutathione –
decreased protection of RBCs from
oxidants-hemolysis.
2. Excess of Vitamin K given IM
23. Under-secretion Hyperbilirubinemia:
Enzymatic Deficiency( Glucoronyl
transferase)
Hormonal suppression (Breast milk
jaundice)
Inhibition of conjugation
Hepatic cell injury due to Infections
Substrate deficiency (hypoglycemia)
Mechanical obstruction (biliary atresia)
24. Hormonal Suppression:
Pregnandiol present in maternal breast milk
suppresses bilirubin conjugation.
Breast feeding may be stopped and
restarted in a period of 48hours.
27. Inhibition of Conjugation:
Sulfonamides and Vitamin K results in
competitive conjugation inhibition of bilirubin.
GALACTOSEMIA:
Absent or deficient Galactose 1phosphoate uridyl transferase which is
needed in glucoronidaton of indirect bilirubin.
29. HISTORY
Maternal and Perinatal History:
Delivery at period of gestation, Postnatal
age in hours.
Maternal illness during pregnancy which
also includes diabetes; drug use.
Previous history of malaria.
Traumatic delivery, delayed cord
clamping, oxytocin use.
Birth asphyxia, delayed feeding, delay in
meconium passage.
30. Family history of jaundice, liver disease
Previous sibling with jaundice for blood
group incompatibility.
Kernicterus: Lethargy, poor feeding, and
hypotonia. Some advanced signs are
seizures, retrocollis, paralysis of upward
gaze and shrill cry.
Breast feeding.
31. ON EXAMINATION:
Baby lethargic, poor feeding, temperature
instability, with apnea: Sepsis
Small for gestation: polycythemia
Cataract, rash: TORCH infections
Extra vascular bleed: Cephalhematoma
Pallor: hemolysis, blood loss
33. HOW DO YOU LOOK FOR
ICTERUS?
1. Dermal staining :progresses from head to
toe
Examined in good day light skin of
forehead, chest, abdomen, thigh, legs,
palms, and soles.
Blanched with digital pressure and the
underlying color of the skin and
subcutaneous tissue should be noted.
34.
35.
36. Clinical Jaundice
Measure Bilirubin
> 12 mg/dl and infant <
24 hr old
< 12 mg/dl and infant > 24
hr old
Fraction of Bilirubin
Follow bilirubin level
Indirect
Direct
37. Direct bilirubin
Evaluate for treatable causes
1.Infections-blood, urine culture, VDRL.
2.Metabolic disorders-urine reducing substances, serum
amino acids,T4,TSH.
If no abnormality ;screen for Identifiable causes
*α-1 antitrypsin deficiency
*cystic fibrosis
*congenital viral infections
If no abnormality; evaluate for anatomical abnormalities
*Stool color
*USG
*Hepato-biliary scintigraphy
*Liver biopsy
41. PHYSIOLOGICAL JAUNDICE
Explain about benign nature of the disease
Encourage to breastfeed frequently &
exclusively
Ask Mother to bring baby back if baby looks
deep yellow or palms & soles have yellow
staining.
43. PHOTOTHERAPY
Mainstay of treatment
Under blue-green light(460490nm), insoluble bilirubin is converted into
soluble isomers that can be excreted in
urine & feces.
To be effective, bilirubin must be present in
skin; hence nor role for prophylactic
phototherapy
44.
45. Term & near term neonates:
The American Academy of Pediatrics (AAP)
has laid down criteria for managing babies
with elevated serum bilirubin based on
gestational age and other risk factors(
hemolysis , asphyxia, low albumin level,
hypothermia)
48. Configurational Isomerization
Z-isomer converted to E-isomer
Reaction is instantaneous but reversible.
After exposure of 8-12 hrs, this constitutes
about 25% of the TSB which is non-toxic.
Excreted slowly from the body; hence not a
major mechanism for decrease in TSB.
51. Administering Phototherapy:
Optimum ambient room temperature( 2528celcius) to prevent hypothermia.
Remove all clothes of baby except diaper
Cover baby’s eyes with an eye patch(to
prevent retinal degeneration) ensuring that it
does not block the baby’s nostrils.
Place the baby under the lights in a cot if
weight is more than 2kg or in an incubator if
baby is small(<2kg)
52. Keep the distance between the baby & the
light 30-45cm.
Ensure optimum breastfeeding as
intermittent feeding sessions.
Monitor temperature of the baby every 24hrs
Measure TSB every 12-24hrs.
Discontinue, once 2 TSB values 12hr apart
fall below current age-specific cut-offs.
Monitor for rebound bilirubin rise within
24hrs.
53. Complications of Phototherapy:
Loose stools
Erythematous macular rash
Purpuric rash associated with transient
porphyrinemia
Over-heating
Dehydration
Bronze baby syndrome
54. Bronze Baby Syndrome
Intense grey-brown discoloration
of the skin, serum, and urine,
especially in premature infants;
when phototherapy was used to
reduce hyperbilirubinemia. Preexisting hepatic disease is
suspected as a cause of the
jaundice and may have
prevented the biliary excretion of
the photo oxidation products of
bilirubin; their retention resulted
in the bronze discoloration.
55. EXCHANGE TRANSFUSION
Double Volume Exchange Transfusion
(DVET) : 160-180ml/kg; is to be performed if
TSB levels reach age-specific cut-offs or if
the infant shows signs of bilirubin
encephalopathy, irrespective of TSB levels.
If baby shows signs of cardiac
decompensation at birth, partial exchange
transfusion with 50ml/kg of packed red cells
should be done to quickly restore oxygen
carrying capacity of blood.
Umbilical venous route.
56.
57. FOLLOWUP
Babies with serum bilirubin>20 mg/dl &
those who required ET should be kept under
follow-up in high-risk clinic for neurodevelopmental outcome.
Hearing assessment should be done at
3months of age.
58. PREVENTION
Ante-natal screening to detect Rh isoimmunization & prompt administration of
Anti D after first obstetric event.
Ensure adequate breast feeding.
Educate parent about danger signs to
ensure immediate checkup.
Follow-up high risk babies( large cephalohematoma, family history of jaundice) for 2-3
days of discharge.
59. JAUNDICE IN THE CHILD &
ADOLESCENT
HISTORY:
Age at onset of symptoms. E.g.: Wilson’s
disease commonly manifests in preadolescents & adolescents.
Past/present use of any drugs
H/o of blood transfusion/ dialysis
Exposure to viral hepatitis
Any h/o of chronic illness;
hemoglobinopathies.