Neonatal jaundice is the condition often seen in infants around the second day after birth. It is mainly caused by
increased levels of bilirubin (physiological jaundice and prolonged jaundice and other non organic causes) and
the symptoms like yellow colour of the skin, dark urine, pale stools. It was assessed by colour of the skin and
severity of jaundice (krammers staging score).Treated by phototherapy, exchange transfusion, pharmacological
agents and natural and home remedies. By this article we concludes that parents should be educated about the
consequences of severe hyperbilirubinemia and simple means to prevent it.
Please find the power point on Phototherapy in jaundice . I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
Please find the power point on Phototherapy in jaundice . I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
Management of child with neonatal jaundiceNEHA MALIK
Newborn jaundice is a yellowing of a baby's skin and eyes. Newborn jaundice is very common and can occur when babies have a high level of bilirubin, a yellow pigment produced during normal breakdown of red blood cells.
follow me on my YouTube channel :- medic o mania
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
Physiological jaundice among newborns/ Icterus neonatorumAakanksha Bajpai
also known as physiological jaundice which is very common among newborns after 24 hours of their birth. it occurs due to immature liver of newborns. it gets cured by exposing the baby to morning sunlight for 7 to 10 days. in preterm babies it might take longers upto 14 days.
Neonatal jaundice (hyperbilirubinemia) by Rajiv MavachiRajiv Mavachi
Jaundice is the most common condition that requires medical attention in newborns. The yellow coloration of the skin and sclera in newborns with jaundice is the result of accumulation of unconjugated bilirubin.
Management of child with neonatal jaundiceNEHA MALIK
Newborn jaundice is a yellowing of a baby's skin and eyes. Newborn jaundice is very common and can occur when babies have a high level of bilirubin, a yellow pigment produced during normal breakdown of red blood cells.
follow me on my YouTube channel :- medic o mania
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
Physiological jaundice among newborns/ Icterus neonatorumAakanksha Bajpai
also known as physiological jaundice which is very common among newborns after 24 hours of their birth. it occurs due to immature liver of newborns. it gets cured by exposing the baby to morning sunlight for 7 to 10 days. in preterm babies it might take longers upto 14 days.
Neonatal jaundice (hyperbilirubinemia) by Rajiv MavachiRajiv Mavachi
Jaundice is the most common condition that requires medical attention in newborns. The yellow coloration of the skin and sclera in newborns with jaundice is the result of accumulation of unconjugated bilirubin.
neontal joudice is is a yellowish discoloration of the skin, sclerae, mucous membranes and nails.
Hyperbilirubinemia is a common and, in most cases, benign problem in neonates.
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
A study to assess the self-esteem among adolescents of alcoholic dependent pa...SriramNagarajan16
Adolescence is a transitional stage of physical and psychological development that generally occurs during the
period from puberty to legal adulthood. Adolescence is usually associated with the teenage years, but its
physical, psychological or cultural expressions may begin earlier and end later. Self-esteem can be defined as an
individual’s judgment of his or her self-worth (Rosenberg 1965). Alcoholism also known as Alcohol use
disorder(AUD), is a broad term for any drinking of alcohol that results in ment al or physical health problems.
Methods
A descriptive research design was done in thrivallur district. 100 samples are included in our study. purposive
sampling techniques method was used in selecting the samples. Rosernberg self-esteem scale, were used to
collect data.
Results
The level of self-esteem among adolescents of alcohol dependent parent. (33%) are low self-esteem, (67%) are
moderate self-esteem, (0%) are high self-esteem.
Conclusion
The overall study finding showed that 67% of the sample had moderate self-esteem among adolescents of
alcoholic dependent parent in Thiruvallur District.
Hazards of OTC medication - a community pharmacy practiceSriramNagarajan16
Over the counter (OTC) medication most common practice in India and concurrently patient complaint due to
OTC encounter by healthcare practitioner also uncountable. In OTC practice one can buy medicines without
prescriptions of register medical practitioner (RMP). In India, peoples are always practice OTC to relieve pain
and treat symptoms of the common cold, flu, and allergies. In present study, a survey was conducted in different
places of central India and collected data especially from Ratlam and Mandsaur District of Madhya Pradesh
state, India. During the survey, information was obtained from the individuals used OTC medication as per predesigned questioners. Subsequently, documented information was evaluated to find out risk of OTC medication,
if any. In evaluation, it was found that about 21% OTC drug may cause moderate to severe hazardous effect to
the patients used OTC medication. Patients with complaints of fever; body ache etc. used only NSAIDs from
OTC and later diagnosed as chikungunya, when complaints persisted and visit doctors’ clinic. OTC medication
has tremendous risk which may fatal for patients and chances of produce new complications due to misuse of
drugs. So, medication should be taken after diagnosis by register medical practitioner that will make a healthy
society.
A review article: antifungal activity of eucalyptus genusSriramNagarajan16
Plant essential oils are intricate blends of organic volatility that may have antifungal characteristics of interest in the
food, cosmetics and human health industries. As a result, in the quest for a natural and secure alternative, surveys of
the antimicrobial activity of essential oils in recent decades have become increasingly essential. This review describes
the anti-fungal therapeutic operations reported in the accessible research papers and scientific references of herbal
Eucalyptus oils from diverse verities. At the same time, a study of significant techniques used in the assessment of
antimicrobial activity and some of the processes involved in antimicrobial activities of essential oils was also carried
out. The focus of this review article is on the characteristics and antimicrobial procedures of Eucalyptus globulus
essential oils and the procedures involved in inhibiting these pathogenic micro-organisms.
The study on anatomy, risk factors, pathophysiology, treatment of osteoarthritisSriramNagarajan16
The review is to describe the osteoarthritis epidemiology, anatomy, pathophysiology, risk factors causing
osteoarthritis are also explained and treatment of osteoarthritis. Knee and hip are weight bearing joints are
mostly affected. Osteoarthritis of the knee is a condition characterized by the progressive destruction of the
cartilage and review tried to explain the stages of the knee and treatment for knee and describe the t otal knee
replacement. The goal of treatment for osteoarthritis of the knee include reduce pain and inflammation and
update treatment also explained.
A review article: antimicrobial and antidiarrheal activity of tinospora cordi...SriramNagarajan16
The objective to the paper emphasizes on the study of various models related to antimicrobial and antidiarrheal
activity of Tinospora cordifolia. The plant also possesses various pharmacological activities including its use as
antihyperglycemic, anti-inflammatory, antiarthritic, ant osteoporotic, enhance cognition (learning and memory),
antidiarrheal and immunomodulatory effects. The current works aims to justify the folklore use of the whole plant
of the Tinospora cordifolia for its antidiarrheal and antimicrobial potentiality. Tinospora cordifolia contains
phytochemical constituent such as alkaloids, diterpenoid lactones, glycosides, steroids, sesquiterpenoid, phenolics,
aliphatic compounds and polysaccharides. T. cordifolia is already an import- tent composition of many traditional
Indian medicine formulations, both its purified stem proteins and the derived peptides by enzyme hydrolysis could
be incorporated into food products or nutraceuticals or developed to be a safe and efficient drug for treating
oxidative stress and related disorders. Pretreatment with Tinospora cordifolia extracts provide significant protection
against castor oil and magnesium sulfate‑induced diarrhea, the extracts may presume to have antisecretory and
preventive action towards CCK release
A review article: a surpass effect of pterocarpus marsupium on peptic ulcer d...SriramNagarajan16
The Pterocarpus marsupium belong to family Fabaceae and is widely distributed in central, western and southern
regions of India. The role of Pterocarpus marsupium as anti-diabetic has been very well established. Its extract has
been prepared using many methods like infusion, maceration, decoction and percolation. Several chemical
constituents like pterostilbene, (-)-epicatechin, pteropines, marsupinol, etc., have been identified and isolated.
Pterocarpus marsupium extract also shows promising results in cataract and hypertriglyceridemia. This plant also
finds its use as cardiotonic and hepatoprotective agent. Studies have also been reported to demonstrate its ability as a
specific COX- 2 inhibitor. The present review explores its description, traditional uses, extraction methods, chemical
constituents, pharmacological activity and commercial significance so that its potential as a multipurpose medicinal
agent can be understood and appreciated.
Rheumatoid arthritis is a chronic inflammatory and systemic auto immune disease affecting people for the most part
between the ages of 20-25 yrs with accidental course. About 1% of the worlds population is afflicted by rheumatoid
arthritis and is 2-3 times more common in women than men. The rheumatoid arthritis due to the presence of pro
inflammatory markers, cytokines and leukotrines. The primary inflammatory markers are IL-1, TNF-α, IL-6, IL-15,
IL-16, IL-17, IL-18, IFN-γ, and the granulocyte macrophage colony stimulating factor, chemokines such as IL-8,
macrophage inflammatory protein-1 and monocyte chemo attractant protein-1. IL-1, TNF-α, IL-6, B cells therapy all
these blockade are therapeutic target for its treatment. estimate the anti arthritic activity of the plants are used in
different animal models to induced arthritis. Medicinal plants have been used as major sources of pure of human
diseases since time immemorial. Now a days most of the people depends on traditional medicines of the plants. The
medicinal plants derived medicines for the first time of primary health care because of least or no side effects.
Preliminary study of Prescription audit for evaluation of prescribing pattern...SriramNagarajan16
Prescription audit is necessary to know the art of prescription practices to improve rational pharmacotherapy.
Present study is an observational study and was undertaken from August 2018 to October 2018 for which data
was collected from Medical OPD. Prescribing is a technique with an expert academic pharmacological
knowledge.
Irrational prescribing leads to diminished therapeutic outcome. The present study is the first preliminary one at
Pandit Jawaharlal Lal Nehru Govt. Medical College and Hospital, Chamba- HP Before July 2016, it was a
district hospital College. It is a hilly district and caters the need of 5 Lakh people. A total of 420 prescriptions
were analyzed. These prescriptions comprised of 3000 drugs. Average drugs prescribed per patient were 7.3 .
male and female ratio was 40% and 60% respectively. More prescription were carried out in the age group of 51
- 60 yrs. Prescriptions in generic were only 3.65% fixed dose combination was used in 300 prescriptions and
comprised of 71.4% drugs. Oral prescriptions were used maximally and intravenous medication was minimally
used. Multivitamin prescriptions were observed in bulk.
A study on prescription pattern and rational use of statins in tertiary care ...SriramNagarajan16
Objectives
Our objectives are to evaluate prescription pattern and rational use of statins in a tertiary care corporate hospital.
Methodology
It was a prospective observational study conducted for a period of 6 months and included various departments of 300
bedded multi specialty tertiary care corporate hospital. A total of 200 patients were included and the study criteria
was inpatients and induvial more than 18 years of either gender who are prescribed with HMG-CoA reductase
inhibitors.
Results
In the present study 200 patients belonged to the age group of above 18 years, out of which about 65% were male
and 35% were female. Atorvastatin (67%) was prescribed mostly and Rosuvastatin (29.5%) was also used.
Conclusion
It is finally concluded that Rational and prophylactic use of statins can reduce further complications of Diabetes
Mellitus (DM) and cardiac events.
Statins treatment is favourable in long term treatment of diseases, it is most effectively used in treatment of serious
disease conditions which has shown its immense therapeutic role in treatment
Antimicrobial activity and phytochemical analysis of whole plant Impatiens ba...SriramNagarajan16
Impatiens balsamina linn, belonging to the family of Balsaminaceae.It is distributed in tropical and sub tropical parts
of India. It issued in emetic, chathartic, diuretic and cancer. Present study is carried out to determine the anti
microbial properties of the ethanol extract of Impatiens balsamina.
A study on drug utilization evaluation of anticoagulant therapy INA tertiary ...SriramNagarajan16
Objectives
Evaluation of a prospective observational study of the Anticoagulants used in tertiary care hospital, to provide
information and correct rationale pertaining to Anticoagulants which also describes various distribution wise of
Anticoagulants by age groups, genders, pattern of prescription, drug wise, dose, route, class and department to assess
the statistical incidence regarding usage and its right provision.
Methodology
Study site was at SUNSHINE HOSPITALS, conducted for a period of 6 months. Both male and female individuals of
age group 16-75years were included.
Results
Study included assessment of utilization of Anticoagulants with total of 200 prescriptions; of which males (54.5%),
females (44.67%), age groups of 60-69 (34%) followed by age groups 70-80(27.5%), parenteral SC route (59%) and
followed by intravenous route. (38%) and oral route was rare (3%), orthopaedics (64, 32%), followed by cardiology
(43, 21.5%), neurology (29, 14.5%), pulmonology (22, 11%).
Conclusion
To conclude with, Anticoagulants are effective drugs in an array of treatment of diseases involving careful
consideration of factors such as potency, formulation, responsiveness and cost. Anticoagulanting agents were mostly
given in cases of post or pre operative care followed by prophylaxis for thrombosis for better patient outcome.
Zinper softgel caps: a natural nutrient helps to ease occasional nausea & pro...SriramNagarajan16
Chemotherapy –induced nausea and vomiting (CINV), also known by the term emesis, is one of the most
common and dreaded side effects following cancer treatment, and can strongly impact the quality of day –today living of cancer patients. Many Chemotherapeutic agents are associated with significant nausea and
vomiting which represent a challenge to effective therapy. The active ingredients present in Zinper softgels are
terpenes and oleoresin. The major identified components from terpenes are gingerol and shogaols. Zinper
softgels has staring potential as anti-tumor, anti-oxidant, anti inflammatory, anti-microbial, anti-emetic effect,
Anti-angiogenesis, anti-nausea and an effective adjuvant treatment for chemotherapy-induced nausea and
vomiting. The effectiveness of Zinper softgels in preventing or suppressing cancer growth has been examined in
a variety of cancer types, including lymphoma, hepatoma, colorectal cancer, breast cancer, skin cancer, liver
cancer, and bladder cancer. This article reviews the current available scientific literature regarding the effect of
Zinper softgels as A Natural Nutrient to Promote Healthy GI peristalsis in cancer patients.
A laboratory bioassay was conducted to investigate the antifeedant effect of Gomphrena serrata extracts on
sitophilus oryzae (rice weevil) belongs to the family Curculionidae. Antifeedants are natural or synthetic
compounds that stops or inhibits feeding by a pest and especially an insect. Gomphrena serrata- Amaranthacae
family comprises many species which are used in nutrition and traditional folk medicine. Study was done to
find the new active substance in the plant which could show antifeedant activity and compared with standard
Strychnos nuxvomica. The extracts of both sample and standard were obtained by cold maceration process. The
residue formed is collected and both the extracts were subjected to study the antifeedant activity. The activity is
performed by dilution method and found to be showing the antifeedant activity. The primary objective of our
work is simple and cost effective method to find out the active substance from natural resources.
Indiscriminate use of synthetic insecticides has led to problems such as the resurgence of primary pests,
secondary pest’s outbreak, resistance development, insecticide residue, health hazards, environmental
contamination and increased cost of insect control. So this study will be solution for these problems by utilizing
plant’s bioactive molecules. Plants are the most efficient producers of phytochemicals in the environment,
including secondary metabolites that are used by the plant in defence against insects. The secondary metabolites
produced from Gomphrena serrata could be utilized in the development of new biopesticides
Morphometric variations of right and left side mandibular foramen from corono...SriramNagarajan16
Background of the study
Variation of the mandibular foramen right and left side is very important ,because to know about the vital
structures passing through it and also the Variation is very important during the intra oral surgery like tooth
extraction, implantation ,mandibular fracture . The knowledge of variation in mandibular formen is very
important to avoid the anaesthestic error of inferior alvelor nerve blockage.
Objectives
The aim of this study is to determine the position of the Mandibular foramen conodylar process, coronoid
process, to the lingua in several dry adult mandibles.
Materials and methods
A total number of 200 human dry mandibles RIGHT AND LEFT SIDE MANDIBULAR FORAMEN were
examined of which 170 mandibles are normal and 30 mandible shows variations with the help of vernier caliber
.Measurement
The Measurement were taken as follows
i)Condylar Process to the Mandibular foramen
ii)Coronoid Process to the Mandibular foramen
iii)Mid portion of lingula to the Mandibular foramen
Result
According to our study, the following are the variations found,The length from the condylar process to the
mandibular foramen is more on right side compared to the left side.The length from the coronoid process to the
mandibular foramen is more on left side compared to the right side.The length from the midpoint lingua to the
mandibular canal is more on right side compared to left side
In vitro and in vivo evaluation on fishes of anti-inflammatory potential of A...SriramNagarajan16
Agaricus bisporus has been studied for many activities except for its anti-inflammatory potential completely both by
in vitro and in vivo experiments. In the present study it was evaluated for the same using egg albumin for in vitro
study and fish as the model for in vivo evaluation and found to have remarkable anti-inflammatory activity on both
experiments. As expected with any natural drug the activity was better at higher doses.
CALCI-Q tablets: The Calcium fortified with mineralsSriramNagarajan16
Calcium is very essential in muscle contraction, oocyte activation, building strong bones and teeth, blood clotting,
nerve impulse, transmission, regulating heart beat and fluid balance within cells. The requirements are greatest during
the period of growth such as childhood, during pregnancy, when breast feeding. Long term of calcium deficiency can
lead to oestoporosis in which the bone deteriorates and there is an increased rise of fractures. Eating a well-balanced
calcium supplment like Calci-q tablet can provide all the necessary nutrients and help prevent calcium deficiency.
The present paper Reviews the Role of Calci-Q tablets developed by R&D cell of Sain medicament Pvt Ltd.
Hyderabad in maintaining optimum health and wellbeing.
Submucosal plasmacytosis is a rare idiopathic condition consisting of a dense plasma cell infilterate of the mucous
membrane.It presents clinically as a diffuse, erythematous and less often ulcers are present .The etiology is still
unclear,but this condition is believed to be an immunological reaction to certain allergens .Here presenting a case
report of 86 year old male complained of multiple oral lesions and bleeding from lip region since one and half month
back,also complains of pain and burning sensation.
Huntington’s disease is an autosomal, dominant, slowly progressive, inherited, incurable, and a
neurodegenerative disease characterized by uncontrolled motor movements, cognitive impairment, behavior
abnormalities which may finally lead to dementia. The main cause of this disease is the mutation in the
huntingtin gene, which is an IT 15 gene. The Occurrence of this disease is more in western countries between
the age group of 35 to 45. Symptoms of this disease depend upon CAG triplet repeat. Main symptoms are
chorea, athetosis, jerks, weight loss, difficulty in speech are seen. Symptomatic treatment may improve the
quality of the life of the individual or may decrease complications.
Transverse Testicular Ectopia (TTE) is a rare congenital anomaly in which both testicles migrate towards the same
side of the scrotum. It is usually associated with other abnormalities such as Mullerian duct syndrome, inguinal
hernia, scrotal anomalies etc. We are presenting a case of Transverse Testicular Ectopia in a 30 year old male patient
having complaints of Left Inguinal Hernia previously operated for Left Orchidopexy with mesh placement.
Phytochemical screening and in vitro antioxidant activity of extracts of jasm...SriramNagarajan16
Objectives
The aims of this research were to carry out the preliminary phytochemical screening and antioxidant activity
of different extracts of J. sessiliflorum. The different anti-oxidant methods carried out were DPPH
scavenging method, NBT dye reduction method and nitric oxide scavenging method
Methods
Extracts were prepared by reflux method using different polarity solvents. The extracts were evap orated
using rotary evaporator. Antioxidant activities using DPPH, NBT dye reduction method and nitric oxide
scavenging methods and the correlation of their IC50 values with standards were carried out.
Results
The ethanolic herbs extract of J. sessiliflorum had the lowest IC50 values in all the anti-oxidant methods.
Moreover, the ethanolic extracts showed the presence greatest amount of phytochemical constituents. The
IC50 values were correlated with the IC50 values of standards in all the anti- oxidant activity determination
methods.
Conclusions
The results of the present study indicate that the extracts of J.sessiliflorum exhibited strong antioxidant
activity and thus it is a good source of antioxidant.
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
Neonatal jaundice- a review article
1. Prakash A et al / Int. J. of Pharmacology and Clin. Research Vol-2(1) 2018 [42-53]
42
IJPCR |Volume 2 | Issue 1 | Jan – Jun- 2018
www.ijpcr.net
Review article Clinical research
Neonatal jaundice- a review article
Rupasri Lakshmi T, Sruthi J, Sartaj SK, Navya V and Dr.A.Prakash*
Department of Pharmacy Practice, Vishwabharathi College of Pharmaceutical Sciences, Guntur 09, Andhra
Pradesh, India
*
Address for correspondence: Dr. A. Prakash
E-mail: apcology@gmail.com
ABSTRACT
Neonatal jaundice is the condition often seen in infants around the second day after birth. It is mainly caused by
increased levels of bilirubin (physiological jaundice and prolonged jaundice and other non organic causes) and
the symptoms like yellow colour of the skin, dark urine, pale stools. It was assessed by colour of the skin and
severity of jaundice (krammers staging score).Treated by phototherapy, exchange transfusion, pharmacological
agents and natural and home remedies. By this article we concludes that parents should be educated about the
consequences of severe hyperbilirubinemia and simple means to prevent it.
Keywords: Hyperbiliruinemia, Jaundice, Phototherapy, Natural remedies.
INTRODUCTION
Jaundice is the condition which is characterised
by yellowish or greenish pigmentation of the skin
and whites of the eyes due to high bilirubin levels.
It is commonly associated with itchiness. The term
“Jaundice” comes from the French language and
means “yellow”. The most common alternative
name for jaundice is Icterus. Other terms include
Yellow Skin and Yellow Eyes. This condition is
most commonly found in new-born and infants,
however, it affects adults as well. The faeces may
be pale in colour and the urine becomes dark.
Jaundice is caused due to the accumulation of
bilirubin (a yellow pigment) in the skin. When
blood cells complete their life cycle, they are
broken down in the body. Bilirubin from these cells
is released, which further gets filtered in the liver
and then excreted. Since the liver of the baby is not
fully developed, it cannot filter the entire bilirubin
formed, which thus accumulates in the skin,
resulting in neonatal jaundice [1]. If bilirubin levels
in babies are very high for too long, a type of brain
damage known as kernicterus may occur [2]. In
neonates, the evaluation of sclera is difficult due to
the presence of physiological photophobia [3].
TYPES OF JAUNDICE
There are three types of jaundice
1. Haemolytic jaundice –It is caused by destruction
of red blood cells. This causes increased
bilirubin formation and anaemia
2. Obstructive jaundice –It is caused by a blockage
in the pathway where bilirubin is made in the
International Journal of Pharmacology and
Clinical Research (IJPCR)
ISSN: 2521-2206
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liver cells and where bile goes into the
duodenum
3. Hepatocellular jaundice –It is caused by damage
to liver cells. The damage could be from a viral
infection or toxic drugs.
Yellow discoloration of the skin and the whites of the
eyes happens in all types of jaundice [4].
NORMAL VALUE OF BILIRUBIN
BILIRUBIN NORMAL VALUE
New Born 0.8 to 12.0 mg/dl
Abnormal Value New-born >15mg/dl
FecalUrobilinogen 40 to 280 mg/day
Urine 0.0 to 0.02mg/dl
NEONATAL JAUNDICE
Neonatal jaundice (or) neonatal
hyperbilirubinemia, (or) neonatal icterus this
condition is often seen in infants around the second
day after birth, lasting until day 8 in normal births,
or to around day 14 in premature births [3]. In
neonates, the yellow discoloration of the skin is
first noted in the face and as the bilirubin level
rises proceeds caudal to the trunk and then to the
extremities. Icteric, is a yellowing of the skin and
other tissues of a newborn infant. A bilirubin level
of more than 85 μmol/l (5 mg/dL) leads to a
jaundiced appearance in neonates. This condition is
common in newborns affecting over half (50–60%)
of all babies in the first week of life. Neonatal
jaundice can make the newborn sleepy and interfere
with feeding. Extreme jaundice can cause
permanent brain damage from kernicterus [5].
Physiology of bilirubin
Bilirubin (formerly referred to as haematoidin
and discovered by Rudolf Virchow in 1847) is a
yellow compound that occurs in the normal
catabolicpathway involving breakdown of heme in
vertebrates. This catabolism is a necessary process
in the body's clearance of waste products that arise
from the destruction of aged red blood cells. First,
the hemoglobin gets stripped of the heme molecule
which thereafter passes through various processes
ofporphyrin catabolism, depending on the part of
the body in which the breakdown occurs. The
production of biliverdin from heme is the first
major step in the catabolic pathway, after which the
enzyme biliverdinreductase performs the second
step, producing bilirubin from biliverdin [5].
1gm of Haemoglobin results in the production of 34mg
bilirubin.
A normal new born produces 6 to 10mg/kg/day of
bilirubin.
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Bilirubin is excreted in bile and urine, and
elevated levels may indicate certain diseases. It is
responsible for the yellow color of bruises and the
yellow discoloration in jaundice. Its subsequent
breakdown products, such as stercobilin, cause the
brown color of faeces. A different breakdown
product, urobilin, is the main component of the
straw-yellow color in urine. There is unconjugated
bilirubin and conjugated bilirubin. In the liver,
bilirubin is conjugated with glucuronic acid by the
enzyme glucuronyl transferase, makingit soluble in
water: the conjugated version is the main form of
bilirubin present in the "direct" bilirubin fraction.
The measurement of unconjugated bilirubin
depends on its reaction with diazosulfanilic acid to
create azobilirubin. [5]
What happens when new born has jaundice
Red blood cells die off in large numbers after death
A lot of bilirubin is produced
Because the liver is not yet mature, it processes bilirubin
Very little bilirubin leaves the body
The excess, unprocessed bilirubin builds up everywhere in the body it colours the skin and eyes become yellow.
SIGNS AND SYMPTOMS
Drowsiness
Pale stools - breast-fed babies should have
greenish-yellow stools, while those of bottle fed
babies should be a greenish-mustard color
Poor sucking or feeding
Dark urine - a new born's urine should be
colourless( Brown urine)
Yellow colour of the skin
High pitch cry
Vomiting [6].
CAUSES OF NEONATAL JAUNDICE
Physiological jaundice
It is attributable to physiological immaturity
usually appears between 24 to 74 hours of age and
peaks by 4 to 5 days in term of 7th
day in preterm
neonates and disappears in 10 to 24 days of life.
This is predominately unconjugated bilirubin
levels, usually, does not exceed 15mg/dl[4]. Most
infants develop visible jaundice due to elevation of
unconjugated bilirubin concentration during their
first week. This pattern of hyperbilirubinemia has
been classified into two functionally distinct
periods [6].
Phase one
1. Term infants - jaundice lasts for about 10 days
with a rapid rise of serum bilirubin up to 204
μmol/l (12 mg/dL).
2. Preterm infants - jaundice lasts for about two
weeks, with a rapid rise of serum bilirubin up to
255 μmol/l (15 mg/dL).
Phase two
Bilirubin levels decline to about 34 μmol/l (2 mg/dL)
for two weeks
1. Preterm infants - phase two can last more than
one month.
2. Exclusively breastfed infants - phase two can
last more than one month
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Prolonged jaundice
Jaundice that lasts until and after 14 days after
birth (or 21 days for premature babies) is called
prolonged jaundice. It may indicate a serious
problem but is most often caused by breast-feeding
[6].
Non organic causes
Breast feeding jaundice
"Breastfeeding jaundice" or "lack of
breastfeeding jaundice," is caused by insufficient
breast milk intake, resulting in inadequate
quantities of bowel movements to remove bilirubin
from the body. This leads to increased
enterohepatic circulation, resulting in increased
reabsorption of bilirubin from the intestines.
Usually it occurs in the first week of life. Most of
the cases can be ameliorated by frequent
breastfeeding sessions of sufficient duration to
stimulate adequate milk production.
Breast milk jaundice:
Breastfeeding jaundice is a mechanical
problem; breast milk jaundice is a biochemical
occurrence and the higher bilirubin possiblyacts as
an antioxidant. Breast milk jaundice occurs later in
the newborn period, with the bilirubin level usually
peaking in the sixth to 14th
day of life. This late-
onset jaundice may develop in up to one third of
healthy breastfed infant [5].
Hemolytic jaundice
The common cause of hemolytic jaundice
include Rh haemolytic disease, ABO
incompatability,G-6PD deficiency, and minor
blood incompatibility.
CLINICAL ASSESSMENT OF
JAUNDICE
Colour of the skin (to be checked in naked baby,
naturalligt, non-yellow background, minimum
blanching over bony surfaces)
Severity of jaundice (krammers staging of
jaundice)
Anemia, signs of dehydration.
Hepatospleenomegaly
Complete neurological examination to look for
s/o of kernectirus.
Special look for cephalohematoma, bruisings or
bulging of AF.
Abdominal mass of distension
Kramers staging score
Area of body Serum bilirubin levels Score
Face 4-6mg/dl 1
Chest ,upper abdomen 8-10mg/dl 2
Lower abdomen,thighs 12-14mg/dl 3
Arms,lower legs 15-18mg/dl 4
Palms,soles 15-20mg/dl 5
TREATMENT
Hyperbilirubinaemia can be treated with:
Phototherapy
Exchange transfusion
Pharmacological agents
PHOTOTHERAPY
The phototherapy was first discovered,
accidentally, at Rochford Hospital in Essex,
England. Infants with neonatal jaundice are treated
with colored light called phototherapy, which
works by changing trans-bilirubin into the water
solublecis-bilirubin isomer [5].
There are two types of phototherapy
Conventional phototherapy: In non-haemolytic
jaundice conventional phototherapy used.
Intensive phototherapy: Intensive phototherapy
is preferred when there is rapidly raised bilirubin
levels and in haemolytic jaundice cases and
ineffective of conventional phototherapy [3].
The main goal of therapy is to lower the
concentration of circulating bilirubin or keep it
from increasing. Phototherapy achieves this by
using light energy to change the shape and structure
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of bilirubin converting it to molecules that can be
excreted even when normal conjugation is
deficient. Absorption of light by dermal and
subcutaneous bilirubin induces a fraction of the
pigment to undergo several photochemical
reactions that occur at very different rates. These
reactions generate yellow stereoisomers of bilirubin
and colourless derivatives of lower molecular
weight. The products are less lipophilic than
bilirubin, and unlike bilirubin, they can be excreted
in bile or urine without the need for conjugation
[6].
Phototherapy is carried out in different methods
Light bank Bilibed Biliblanket
Equipment Isolette/open cot according to unit policy.
May be used in conjunction with a
biliblanket.
Open cot or as per
manufacturer‟s
recommendation.
Consider adding/changing
to bank of lights if total
serum bilirubin level
continues to rise.
Open cot or in
conjunction with light
bank in isolette.
May be used in
conjunction with a
bank of lights.
Clothing Remove all clothing except disposable
nappy.
No lotions/lubricants on skin.
Remove all clothing except
disposable nappy.
Dress only in
manufacturer‟s jumpsuit to
maximise exposure to light.
No lotions/lubricants on
skin.
Remove all clothing
except disposable
nappy.
Place fiberoptic pad
between skin and
singlet.
No lotions/lubricants
on skin.
Temperature Hourly for first 4 hours then
3 – 4 hourly.10
Phototherapy may lead to an elevated
isolette temperature. Do not turn the
isoletteoff, it is not safe to nurse a baby in
an isolette that has been turned off as air
no longer circulates.
Cover temperature probe with reflective
disc if servo control method is used to
monitor temperature.
Hourly for first 4 hours then
3 – 4 hourly.10
Hourly for first 4
hours then 3 – 4
hourly.10
Other
observations
As per clinical condition and/or maturity. Check for skin rashes. Report dark urine and/or light
(pale) stools.
Eye patches Required to protect immature retina.1,9
Monitor hourly to check for eye
discharge.
Remove with feeds/cares.10
Replace after feeds/cares before
commencing phototherapy.
Not required.
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Feeds Demand feeds if breastfeeding or at least
3 - 4 hourly or as age appropriate.
Observe breastfeeding.
Document input output.
Weigh daily.
May need to increase daily fluid volume
intake.
Demand feeds if
breastfeeding or at least
3 - 4 hourly.
Observe breastfeeding.
Document input output.
Weigh daily.
Demand feeds if
breastfeeding or at
least
3 - 4 hourly.
Observe
breastfeeding.
Document input
output.
Weigh daily.
Position Position babies under phototherapy supine at all times in accordance with safe Infant sleeping
guidelines.11 All babies nursed in neonatal units should only be placed in the prone position if
continuous cardiorespiratory monitoring is used.11
Bilirubin
measurements Switch off light during blood collection.
Complications of phototherapy
Babies with congenital erythropoietic porphyria
can develop severe blistering and
photosensitivity during phototherapy. Congenital
porphyria or a family history of porphyria is a
contraindication to the use of phototherapy.
Intestinal hypermotility, diarrhoea.
Separation of mother and baby causing
interference of mother baby interaction (if
facility is unable to keep mother and baby
together while baby receives phototherapy).
Parents find eye patching disturbing.
Changes in the baby‟s thermal environment lead
to increased peripheral blood flow and insensible
water loss.
Babies with cholestatic jaundice may
development „bronze baby syndrome‟ and rarely
purpura and bullous eruption.
Concomitant use of certain drugs or agents may
cause photosensitivity [7].
EXCHANGE TRANSFUSION
This treatment is used when bilirubin levels are
extremely high or are increasing too quickly to be
treated by phototherapy .It is removing the infant‟s
blood and replacing it with blood matched for
blood group that is free of bilirubin. Extremely
high levels of bilirubin can injure the brain
(kernicterus) and lead to severe neurological
impairment [8]. Immediate exchange transfusion is
recommended even if the total serum bilirubin level
is falling if a baby is jaundiced and displays signs
of intermediate to advanced stages of acute
bilirubin encephalopathy which include:
Lethargy, hypotonia, poor feeding with high
pitched cry
Hyper alert or irritable
Hypertonia, arching, retrocollis- opisthotonos
Obtunded to comatose, apnoea, seizures
As blood collected after an exchange
transfusion is of no value for investigating many of
the rarer causes of severe hyperbilirubinemia, these
investigations should be considered before
performing exchange transfusion.
PHARMACOLOGICAL TREATMENT
Intravenous Immunoglobulin (IVIG)
IVIG reduces bilirubin concentrations in babies
with rhesus haemolytic disease and other immune
haemolytic jaundice. Babies with a positive DAT
who have predicted severe disease based on
antenatal investigation or have an elevated risk of
progressing to exchange transfusion based on the
postnatal progression of total serum bilirubin
levels, should receive IVIG.1 The dose required is
1 g/kg1 given intravenously over 2 hours.
The use of IVIG may be recommended in special
circumstances such as:
Parental refusal for exchange transfusion
Where appropriate blood components for
exchange transfusion are unavailable
Phenobarbitone
May improve bile flow but is not recommended
for treatment of hyperbilirubinaemia. It improves
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hepatic uptake conjugation and excretion of bile flow
and reduces bilirubin level. When used
prophylactically in a dose of 5mg/kg for 3 to 5 days
after birth it was shown to be effective in babies with
hemolytic disease , extravascular blood and in
preterms without any significant side effects. [3]
Ursodeoxycholic acid
May improve bile flow and lower bilirubin
concentrations. Use only after discussion with a
Neonatologist and/or gastroenterologist [7].
Hemeoxygenase inhibitors
The rate-limiting step in bilirubin production is
the conversion of heme to biliverdin by
hemeoxygenase. Certain synthetic
metalloporphyrins are powerful competitive
inhibitors of hemeoxygenase and suppress the
formation of bilirubin. One such compound that has
been studied extensively is tin mesoporphyrin
(SnMP). A series of controlled clinical trials have
demonstrated that SnMP is a potent inhibitor of
hemeoxygenase and is highly effective in reducing
TSB levels and the requirements for phototherapy
in term and preterm neonates. The only reported
adverse effect has been a transient erythema that
disappeared without sequelae in infants who
received white light phototherapy after SnMP
administration. This drug isstill awaiting approval
by the US Food and Drug Administration, although
it can be obtained for compassionate use (InfaCare
Pharmaceutical Corp, Trevose, PA, USA). If
approved, SnMP could find immediate application
in preventing the need for exchange transfusion in
infants who are not responding [7].
NATURAL REMEDIES COMMONLY
USED TO TREAT JAUNDICE
Herbal Remedies
Several herbs have been used for hundreds of
years to help buildup a strong liver. These herbs can
also help fight against jaundice. Some commonly
used herbs include:
1. Bitter Luffa
2. Radish Leaves
3. Tomatoes
4. Snake Gourd Leaves
5. Pigeon Pea Leaves
6. Sugarcane Juice
7. Lemon Juice
8. Barley Water
9. Jaundice Berry (also known as Berberisvultaris)
Most of these herbs can be found at a local
Herbologist‟s or Naturalist‟s office, and some can
be found at general nutrition centers and
department stores. Proper home care of jaundice is
best provided by receiving adequate physical rest.
Recovery is dependent upon the liver being able to
handle the amount of bilirubin from destroyed
blood cells. Blood cells are destroyed less when a
person is sleeping or resting than when they are
physically active. Patients should drink plenty of
juice of all kinds throughout the day and be on a
light carbohydrate diet [39].
Home Remedies
Expose to Sunlight
In case of slight jaundice, treatment may not be
required. However, the following step after
consulting your doctor can be tried out. You should
place your baby in sunlight for around fifteen
minutes every day, at least 4 times a day. The
baby‟s skin should be exposed and the glass
window should be closed to filter sunlight. The
bilirubin in the skin gets dissolved due to the
sunlight and gets excreted through urine.
Home-Lamp Therapy
This therapy can be tried when the bilirubin
level is increasing instead of reducing and it is an
alternative treatment to keeping the baby in the
hospital. If the bilirubin levels are unusually high,
keep the baby under special sun lamp. A new type
of treatment is to wrap the baby in a bili-blanket
which reduces the bilirubin. This is a very easy way
of home treatment for mild case of jaundice.
Frequent Feeding
Hydration is essential for flushing out excess
bilirubin from the body. For this reason, frequent
breast-feeding is very essential. Initially less milk
is produced and breast-feeding frequency is also
less which can be a contributing factor for early
jaundice. If the frequency is increased, milk
production also increases. Baby should be fed
every 2 -3 hours and when he wakes up at night. In
case the breast milk is inadequate, formula
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supplements might be required to increase
hydration and help in the excretion of bilirubin.
Feeding of Wheat Grass Juice
Wheat grass juice increases the enzymatic
action in the liver and improves the ability of the
liver to remove excess bilirubin from the body.
Wheat grass juice can be added to the formula
given to the baby. Around 20 drops per day of juice
added to the formula work swell. Alternatively, the
mother can drink 2 ounces of juice every day which
will pass on to the baby through breast milk. This
can be continued till jaundice fades and also helps
prevent jaundice.
Providing Herbal Supplements to the Mother
Supplements like Dandelion tea, catnip,
comfrey leaf and agrimony contain certain
substances which help in detoxifying. The mother
can take these supplements so that it can pass on to
the baby through the breast milk. These natural
detoxifiers help in flushing out the excess bilirubin
from the baby‟s body. Mother should continue
breast-feeding so that this mild treatment continues
to work and help in getting rid of jaundice.
Temporary Stoppage of Breast Feeding
If the doctor informs you that the jaundice has
occurred due to breast milk, you might have to
temporarily discontinue feeding your baby. To
ensure that you continue to produce breast milk,
you can pump your breast every day and start
breast feeding once the doctor gives you permission
to. [7]
Surgical Treatments For Jaundice
Gall stones can often be the cause of jaundice in
adults. In this case, a surgeon may opt to remove the
gallstone and remove any excess bile from the patient.
Blood transfusions can be performed on infants and
adults who experience sever jaundice. Aside from
these cases, surgery is not necessary in the treatment
of jaundice. In the case of a severe liver problem that
is also accompanied by jaundice, the patient may be
required to have a liver transplant. [1]
REVIEW LITERATURE
Bolajoko O. Olusanya et al Maternal detection
of neonatal jaundice during birth hospitalization
using a novel two-coloricterometer. Some 2492
mother-infant pairs were enrolled over 15 months,
of which 347 (13.9%) chose Dark Yellow. The
mean TcB for Dark Yellow (10mg/dL) was
significantly higher (p<0.001) than for Light
Yellow (6.1mg/dL). Bilistrip™ showed increasing
sensitivity (47.0% - 92.6%) and negative predictive
value (NPV) (91.4% - 99.9%) for selected TcB
thresholds (≥10mg/dL, ≥12mg/dL, ≥15mg/dL, and
≥17mg/dL). Among neonates with TSB
measurements (n = 124), Bilistrip™ was associated
also with increasing sensitivity (86.8% - 100%) and
NPV (62.5% - 100%). The sensitivity and NPV for
detecting neonates requiring phototherapy were
95.8% respectively. Only one of the 24 neonates
who required phototherapy was missed by the
Bilistrip™.They concluded that Bilistrip™ is a
potential decision-making tool for empowering
mothers to detect neonates with clinically
significant jaundice that may require close
monitoring or treatment, and neonates not requiring
treatment for jaundice in the first week of life[10].
Vinod K. Bhutani et al studied Identification of
neonatal haemolysis: an approach to pre discharge
management of neonatal hyperbilirubinemia.
Relative contributions of increased production [by
end-tidal carbon monoxide concentrations
(ETCOc)] and decrease elimination of bilirubin to
pre discharge hour specific total bilirubin (TB)
levels were assessed in healthy late-preterm and
term new borns. Secondly, they report pre
discharge ETCOc ranges to guide clinical
management of hyperbilirubinemia. TB and ETCOc
(≤3 time points) determinations of new borns aged
between six hours and <6 days (n = 79) were
stratified by postnatal age epochs.
Hyperbilirubinemia risk was assessed by plotting
TB values as a function of ETCOc. Stratifications
of ETCOc (in ppm, mean, median and interquartile
ranges) by postnatal age epochs (0–24, 24–48 and
48–72) were as follows: 2.0, 1.9, 1.8–2.2 (n = 11);
1.6, 1.5, 1.1–2.0 (n = 58); and 2.0, 1.8, 1.6–2.3 (n =
9), respectively. Infants with ETCOc≥ 2.5 were at
high risk, between 1.5 and 2.5 at moderate risk and
≤1.5 were at low risk. Risk due to haemolysis alone
was not independent (p < 0.01). For infants with
TB >75th percentile (n = 31), 23% had ETCO ≤1.5,
and 77% had ETCOc> 1.5 (p < 0.00003). Finally
they concluded that Near-simultaneous ETCOc and
TB measurements in infants with TB >75th
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50
percentile accurately identify haemolytic
hyperbilirubinemia [11].
Sanjiv B Amin et al studied auditory toxicity in
late preterm and term neonates with severe
jaundice. They compared TSB, bilirubin: albumin
molar ratio (BAMR), and unbound bilirubin for
their association with auditory toxicity in neonates
with severe jaundice (TSB ≥342lmol/L, or that met
exchange transfusion). Twenty-eight out of 100
neonates (mean gestational age 37.4wks; 59 males,
41 females) had auditory toxicity. Peak unbound
bilirubin, but not peak TSB and BAMR, was
associated with auditory toxicity (p<0.05) in
neonates with severe (TSB <427.5lmol/L) and
extreme hyperbilirubinemia (TSB ≥427.5lmol/L).
Area under the receiver operating characteristic
curve for unbound bilirubin (0.78) was
significantly greater (p=0.03) than TSB (0.54)
among neonates with severe but not extreme
hyperbilirubinemia. The mean peak TSB and
unbound bilirubin for neonates were 24.2mg/dL
(SD 4.9) and 1.84lg/dL (SD 1.91) respectively.
Finally they concluded that Unbound bilirubin is
more strongly associated with auditory toxicity
than TSB and/or BAMR in greater or equal to 34
weeks gestational age neonates with severe
jaundice. Unbound bilirubin is a better predictor
than TSB in neonates with severe
hyperbilirubinemia [12].
Shweta Singh et alA Study on Identification of
Newborn at Risk of Hyperbilirubinemia in NCR,
Delhi. Out of 205 neonates 51 developed peak
serum bilirubin level more than or equal to 13 mg/dl
while 154 neonates had serum bilirubin level below
13mg/dl. Thus, the incidence of hyperbilirubinemia
was 24.8%. Neonatal factors like low gestational age,
low birth weight, lower apgar score, history of
jaundice in sibling and maternal factors like mothers'
blood group, use of oxytocin and PROM are
significantly associated with neonatal
hyperbilirubinemia. In our study PROM >18 hours
was associated with neonatal hyperbilirubinemia (p
value of TSB levels = 0.013) which could be
explained by increased risk of infection in a case of
PROM , Use of oxytocin during labor irrespective of
its dose and duration of use was related with
hyperbilirubinemia they concluded that In resource
limited healthcare settings, the cord-blood and clinical
screening of the neonates with risk factors would
prevent prolonged hospitalization and cost as well as
readmission because of neonatal jaundice [13].
Sahoo et al studied the neonatal jaundice in a
tertiary care centre of South India and they
observed that Out of 560 new borns, 273 (48.8%)
new borns developed clinical jaundice, 166 (61%)
new borns developed physiological jaundice and
107 (39%) new borns developed non physiological
jaundice they concluded that Breastfeeding
jaundice tops the list in non physiological jaundice.
it was stated that decreased volume and decreased
frequency of feedings may result in mild
dehydration and the delayed passage of meconium.
(total serum bilirubin level above 12 mg per dL).
ABO incompatibility has become the second most
common cause of non physiological jaundice.
Prematurity was third most common cause in our
study. Preterm new borns are prone to developing
jaundice due to immaturity of bilirubin conjugating
system, higher rate of hemolysis, increased enter
ohepatic circulation, decreased caloric intake [14].
Manjubala dash et al studied to assess the
knowledge and attitude on neonatal jaundice among
the mothers in a selected village of puducherry
among the 50 mothers only one (2%) mother had
adequate knowledge based on describes that
45(90%) of the mothers were able to identify the
areas were yellowish discoloration occurs, 43(86%)
were able to identify danger signs. In relation to
their attitude it showed that 15(30%) mothers had
positive attitude towards the management pattern of
the baby on jaundice– that is taking the baby to
hospital for treatment, continuing breast feeding
etc. [15].
Girish N et al Evolving Trends:
Hyperbilirubinemia among New borns Delivered to
Rh Negative Mothers in Southern India. Anti-D
prophylaxis and advances in neonatal care have
reduced the frequency of HDN by almost a factor
of 10 to 1 in 21,000 births. Out of 100 babies
enrolled, 57 babies developed jaundice. Jaundice is
2.7 times more likely associated with babies born
to multiparous Rh-ve mothers with p=0.017*.
Jaundice is 3 times more likely associated with
Rh+Ve babies born to multiparous mothers with
p=0.020*. Jaundice is 3.97 times more likely
associated with Rh+Ve babies born to multiparous
mothers who have not received Anti-D with
p=0.154. Treatment of jaundice is 2.75 times more
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51
likely in Rh+ve babies born to multiparous mothers
who have not received Anti-D with p=0.162.
Duration of phototherapy is significantly more in
Rh+ve babies born to multiparous mothers who had
not received Anti-D with p=0.0097*.Exchange
transfusion was required in two babies. In the
present study, out of the 3 babies born to
multiparous mothers in whom direct coombs test
was positive, 2 babies had cord blood hemoglobin
level of <11gm% with cord blood bilirubin level of
>4.5mg%. Exchange transfusion was done in these
2 babies with subsequent phototherapy. One more
baby had cord blood bilirubin level of >4.5mg%
with cord blood hemoglobin level >11gm%. In this
case, the mother‟s blood group was O-ve and the
baby was B+ve. This baby was treated with double
surface phototherapy only.They concludes that
Although the incidence of Rh isoimmunization has
declined dramatically over the years, it is still an
important cause of neonatal morbidity and
mortality emphasizing the need for more vigorous
preventive efforts and up-to-date management
skills [16].
Shaheena Kamal et al studied the Breast Non
Feeding: Main Cause of Neonatal
Hyperbilirubinemia in Areas Adjoining Shri Ram
MurtiSmarak Institute of Medical Sciences, A
Tertiary Care Teaching Hospital, Bareilly. 124
newborns with jaundice were enrolled in the study.
Out of 124 cases of neonatal hyperbilirubinemia,
24 cases were of physiological jaundice,84- breast
non feeding jaundice,5- breast milk jaundice,
jaundice due to prematurity-5 and6- pathological
jaundice. Insufficient caloric intake resulted from
maternal and/or infant breast feeding difficulties
may also increase unconjugated serum bilirubin
concentration. There is history of
hyperbilirubinemia in siblings of 30% of cases.
Klebsiella & pseudomonas was detected in blood
culture of two cases conferring the diagnosis of
neonatal sepsis. TSH & T4 levels in neonatal
hypothyroidism were highly abnormal.
Reticulocyte count is highest in ABO
incompatibility cases as hemolysis is maximum in
these newborns. Conjugated bilirubin level & liver
function tests were highly abnormal in case of
congenital biliary atresia and finally they
concluded that breast feeding/non feeding is the
most common cause ofneonatal hyperbilirubinemia
[17].
Shiyam Sundar Tikmani et al Incidence of
neonatal hyperbilirubinemia: a population-based
prospective study in Pakistan. Clinical assessments
of jaundice were assigned by a physician and
recorded using an adapted Kramer scale. Blood for
plasma bilirubin was obtained if parents consented.
Of a birth cohort of 1690 young infants during the
study period, 466 infants (27.6%) were referred to
our centre with jaundice. Of these, 64% were 0-6
days old. Bilirubin was measured in 125 of 466
(27%) jaundiced newborns. Overall detected rate of
hyperbilirubinemia (bilirubin >5 mg/dl) among
1690 newborns was 39.7/1000 live births (95% CI
29.3–47.6). Rate of plasma bilirubin levels in the
range of 15–20 mg/dl was 13/1000 live births (95%
CI 7.6–18.4); levels >20 mg/dl were observed in
3.5/1000 live births (95% CI 0.4–5.5). The
proportion of newborns with bilirubin ≥15 mg/dl
was significantly higher among those assigned a
Kramer score of 4–5 compared to those receiving a
score of 1–3 (P value 0.00004).they concluded that
A significant burden of untreated severe neonatal
jaundice, causing potential neurological sequelae,
exists in developing countries such as Pakistan.
WHO guidelines are needed for screening and
appropriate management of neonatal jaundice in
developing countries [18].
KhalafMreihil et alstudied Early Isomerization
of Bilirubin in Phototherapy of Neonatal Jaundice.
Twenty jaundiced neonates were treated with
phototherapy, and blood samples were drawn
before and at ~15, 30, 60, and 120 min (10 infants)
or at ≈15, 60, 120, and 240 min (10 infants) after
beginning phototherapy for determination of TSB
and 4Z, 15E photoisomers of bilirubin. Significant
(p < 0.0001) formation of the 4Z, 15Ephotoisomer
was detectable within 15 min. The change in TSB
from time 0 was insignificant at 120 min but
reached significance at 240 min (p < 0.001). The
4Z, 15 E bilirubin constituted up to 20–25% of
TSB at 2 h and may not have peaked by 4 h.Further
studies are needed to determine whether this early
shift in balance between bilirubin isomers with
different polarities may impact the risk of bilirubin
encephalopathy even before TSB starts to fall [19].
PREVENTION
The best prevention of infant jaundice is
adequate feeding. Breast-fed infants should have
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eight to 12 feedings a day for the first several days
of life. Formula-fed infants usually should have 1
to 2 ounces (about 30 to 60 milliliters) of formula
every two to three hours for the first week.
CONCLUSION
Preterm newborns are prone to developing
jaundice due to immaturity of bilirubin conjugating
system, higher rate of hemolysis, increased enter
hepatic circulation, decreased caloric intake. There
are 30-40% of normal term newborns develop
transient jaundice 3 to 5days after birth. The most
common cause of occurring hyperbilirubinemia is
inadequate breast feeding to the newborn. Parents
should be educated about the consequences of
severe hyperbilirubinemia and taught simple means
to prevent it. Exclusive breast feeding without
prolonged periods of fasting, and avoidance of
supplementation with dextrose or water is some
documented measures associated with lower serum
bilirubin levels in newborns. Hence government
and health service organisations should conduct
workshops, seminars and lectures for mothers
regarding neonatal jaundice.
ACKNOWLEDGEMENT
The authors are thankful for the management of
Vishwabharathi College of Pharmaceutical
Sciences, Perecherla, Guntur and A.P for providing
facilities for carrying out this review article.
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