This document defines jaundice as hyperbilirubinemia, an excessive level of bilirubin in the blood, and differentiates between physiological and pathological jaundice. It states that kernicterus, caused by unconjugated bilirubin deposits in the brain, is the most dangerous complication. An approach to evaluating a jaundiced baby includes assessing age, risk factors, and signs of kernicterus, and determining if jaundice is physiological or pathological by considering time of onset and duration. Workup may include bilirubin levels, blood typing, and additional tests depending on the situation. Treatment options include increasing feeding, phototherapy, and exchange transfusion for more severe cases.

1. JaundiceBy Bish

2. ObjectivesDefine hyperbilirubinemia (Jaundice).

3. Differentiate between physiological and pathological jaundice.

4. State causes of hyperbilirubinemia.

5. Describe the most dangerous complication of hyperbilirubinemia.

6. Discuss the management of hyperbilirubinemiaDefinition: HyperbilirubinemiaHyperbilirubinemia: excessive level bilirubin in the blood characterized by jaundice, a yellowish discoloration of the skin, sclerae, mucous membranes and nailsTypically seen at bili levels of: 85-120Unconjugated bilirubin = Indirect bilirubin.Conjugated bilirubin = Direct bilirubin.

7. Why am I learning this?Is it important?

8. Why?Jaundice is quite common Full term infants: at least 60% Preterm infants: over 80%

9. Most Importantly…

10. Most Importantly…Kernicterus: unconjugated bilirubin deposits in the brain  yellow staining + degenerative lesionsPhase 1: decreased alertnessHypotonia Poor feeding Phase 2: Hypertonia, Retrocollis, opisthotonus Phase 3: Hypotonia

11. Source Of Bilirubin85% from old RBC , the rest from non haem proteins Hb is degraded to Haem and Globin Iron is extracted from Haem Rest is converted to bilirubin Bilirubin travels to liver bound to albumin

12. Journey through the liver Bilirubin taken up Conjugated to form water soluble conjugate Conjugate secreted into bile

14. In The GutBilirubin diglucuronide may be Deconjugated or Metabolised by bacteria to urobilinogenpartially reabsorbed (remainder makes the stool brown)

15. So where can things go wrong?

16. Pathophysiology Of JaundiceHyperbilirubinemia is due to:Excess bilirubin production Haemolytic

17. Impaired uptake by hepatocyte Hep/cellular.

18. Failure of Conjugation Hep/cellular.

19. Impaired secretion of conj.bil. Hep/cellular.

20. Impaired bile flow. Obst.JaundiceClassifications

21. Classifications Physiological Jaundice Pathological Jaundice

22. Physiological jaundice :1. General state of baby is well 2. Appears 2-3days 3. Disappears <2 week (term infants) <4 weeks (preterm infants)Pathophysiologyincreased hematocrit and decreased RBC lifespan immature glucuronyltransferase enzyme system (slow conjugation of bilirubin) increased enterohepatic circulation

23. Pathological Jaundice 1. Appears earlier (first 24 hours of life) 2. Fades >2 weeks (term infants) >4 weeks (preterm infants)

24. Back to our table..let’s break things down into basics..

25. Hint…

26. Good Job!

27. Now that you’re a pro..You’re called by a nurse for a new admission regarding a baby with elevated bili..what do you want to know

28. Approach to jaundiced babyGet age of baby (hours), gestational age, pregnancy hx, septic risk factors, complications with deliveryAssess clinical condition (well or ill)Decide whether jaundice is physiological or pathologicalLook for evidence of kernicterus* in deeply jaundiced NB*review..what do you look for?

29. Approach to jaundiced babyGet age of baby (hours), gestational age, pregnancy hx, septic risk factors, complications with deliveryAssess clinical condition (well or ill)Decide whether jaundice is physiological or pathologicalLook for evidence of kernicterus* in deeply jaundiced NB*Lethargy and poor feeding, poor or absent Moro's, opisthotonus or convulsions

30. Why does the age (hours) of baby matter?

31. Causes of jaundiceAppearing within 24 hours of ageHemolytic disease of NB : Rh, ABOInfections: TORCH, malaria, bacterialAppearing between 24-72 hours of lifePhysiologicalG6PD deficiencyDehydration (breast feeding jaundice)SepsisPolycythemiaConcealed hemorrhageIntraventricular hemorrhageIncreased entero-hepatic circulationAppearing beyond 1 weekBreast milk jaundiceProlonged physiologic jaundice in pretermHypothyroidismNeonatal hepatitis Conjugation dysfunction - e.g. Gilbert syndrome, Crigler-NajjarsyndromeInborn errors of metabolism - e.g. galactosemiaBiliarytract obstruction - e.g. biliaryatresia

32. What workup/labs do you order

33. WorkupInitial laboratory tests Total & direct bilirubin Blood group and Rh for mother and baby CBC/d, reticcount and peripheral smear CoombtestTSH, G6PD screen Conjugated hyperbilirubinemia: AST, ALT, PT, PTT, serum albumin, ammonia, TSH, TORCH screen, septic work-up