Neonatal jaundice

1. NEONATAL
HYPERBILIRUBINEMA
Akshaya O S
Roll no:14

2. Neonatal hyperbilirubinemia
Definition:
Jaundice is the yellow color
of the skin and sclerae caused
by deposits of bilirubin.
When is visible?
Adult sclera > 2mg/dl
Newborn skin > 5 mg/dl

3. Incidence of
neonatal
jaundice
Incidence in Term :Occurs in 60%
Preterm : 80% of preterm neonates
Jaundice is the most common
condition that requires medical
attention in newborns
Mainly unconjugated or indirect
hyperbilrubinemia is seen in
newborn

5. Mechanisms of Neonatal Jaundice

6. Types of jaundice
PATHOLOGICAL
JAUNDICE
● Appears within 24 hours of age
● Increase of bilirubin >5 mg/dl/day
● Serum bilirubin > 15 mg/dl
● Jaundice days Jaundice persisting after 14
days.
● Stool clay/white colored and urine
staining yellow staining clothes
● Direct bilirubin > 2 mg/dl
PHYSIOLOGICAL
JAUNDICE
● Appears after 24 hours
● Total bilirubin rises by less than 5 mg/dl
per day
● Maximum intensity by 4th-5th day in term
&7th day in preter
● Serum level less than 15 mg/dl Clinically
not detectable after 14 days

7. CAUSES
Of
Neonatal
jaundice
In 1st 24 Hours:
1-Hemolytic disorders (G6PD-Spherocytosis)
2-TORCH (congenital infection)
2nd day- 3rd week:
1-Physiological (disappear after the 1stweek)
2-Breast milk
3-Sepsis
4-Polycythemia
5-Cephalhematoma
6-Criggler-Najjar Syndrome
7-Hemolytic disorders
Appearance or Persistence after 3rd week:
1-Breast milk
2-Hypothyrodism
3-Pyloric stenosis
4-Cholestasis

9. Breastfeeding Jaundice
● Jaundice appears between 24 and 72 hours of age, peaks by 5-15
days of life and disappears by the third week of life.
● Mild clinical jaundice in the third week of life, which may
persist into the 2nd to 3rd month of life in a few babies.
● This increased frequency of breastfeeding jaundice is due to
inadequate breastfeeding.
● Ensuring optimum breastfeeding would help decrease this kind of
jaundice.

10. Breast Milk Jaundice
● 2-4% of exclusively breastfed term babies have jaundice.( in excess of 10 mg/dL
beyond 3rd-4th weeks of life.)
● These babies should be investigated for prolonged jaundice if this is unconjugated
(not staining nappies); and other causes for prolongation have been ruled out.
● Etiology:- Pregnanediol and free fatty acids in breast milk interfere with the
conjugation,increased enterohepatic circulation
● Mothers should be advised to continue breastfeeding at frequent intervals and
TSB levels usually decline over a period of time.
● Some babies may require phototherapy.

11. HISTORY-POINTS TO BE ASKED

12. Examination

13. Clinical Estimation
● Described by Kramer
● Dermal staining of bilirubin may be used as a clinical guide to the level of jaundice.
Dermal staining in newborn progresses in a cephalocaudal
direction. The newborn should be examined in good daylight. The
skin of forehead, chest, abdomen, thighs, legs, palms and soles
should be blanched with digital pressure and the underlying color
of skin and subcutaneous tissue should be noted.
● Yellow staining of palms and soles is a danger sign and requires urgent serum bilirubin
estimation and further management.
Non invasively,bilirubin levels can be assessed by transcutaneous bilirubinometer

14. Serum levels of total bilirubin are approximately
4-6 mg/dL (zone 1),
6-8 mg/dL (zone 2)
8-12 mg/dL (zone 3)
12-14 mg/dL (zone 4)
15 mg/dL (zone 5)
Yellow staining of palms and
soles is a DANGER SIGN

15. TRANSCUTANEOUS BILIRUBINOMETER

16. Complications

17. ● Lethargy
● Poor sucking
● Poor or absent Moro's
● Retrocollis-opisthotonos
● Convulsions
Clinical Features of Acute Encephalopathy

18. Clinical Features of Chronic Encephalopathy
● Athetosis
● Upward gaze
● Sensorineural hearing loss
● Dental enamel hypoplasia

19. MANAGEMENT

22. INVESTIGATIONS
FIRST LINE
• Total serum bilirubin
and its fractions
• Blood groups of
mother and baby
• Peripheral smear
SECOND LINE
• Hematocrit
• G6PD levels
• Sepsis screen
• TFT
• Urine for reducing substances
• Specific enzyme

23. 1.Phototherapy
PRINCIPLE

24. ● Phototherapy is an effective and safe method for reducing indirect bilirubin levels,
particularly when initiated before serum bilirubin increases to levels associated with
kernicterus.
● In term infants - indirect bilirubin levels between 16 and 18 mg/dL.
● premature infants - bilirubin is at lower levels, to prevent bilirubin from reaching the
high concentrations necessitating exchange transfusion.
● Blue lights and white lights are effective

25. PRINCIPLES
1.Configurational isomerization :- Z isomers of bilirubin are converted to E
isomers.The reaction is instantaneous upon exposure to light but reversible as bilirubin
reaches the bile duct.
2.Structural Isomerization:- Irrevrsible reaction where bilirubin is converted into
lumirubin.The reaction is directly proportional to dose of phototherapy.responsible for
the main decline in TSB

26. TYPES OF PHOTOTHERAPY LIGHTS
● Compact flouroscent lamps
● Halogen bulbs
● High intensity LED
● Fibreoptic light source
With easy availability and low cost in
Inida,CFL phototherapy is being most
commonly used device.Often CFL devices

27. Side effects of phototherapy
● Increased insensible water loss
● Loose stools
● Skin rash
● Bronze baby syndrome
● Hypertherma
● May result in hypocalcemia

28. 2.Exchange transfusion

29. ● Exchange transfusion usually is reserved for infants with dangerously high indirect
bilirubin level who are at risk for kernicterus.
● The exchangeable level of indirect bilirubin for other infants may be estimated by
calculating 10% of birth weight in grams

30. STEPS
● Normal blood volume in neonates – 80 ml/kg in a full term baby.
● Therefore 160 ml/kg of blood is required for exchange transfusion (after blood
grouping and cross matching ).
● Procedure has to be performed under complete aseptic precautions.
● Baby placed in supine position.
● Perform Umbilical vein catheterization and confirm position by radiograph.
● If isovolumetric double exchange is to be done umbilical artery catheter is to be
inserted.
● Have the unit of blood ready.Attach the bag of blood to the tubings and confirm
orientation of 3 way stopcocks.

31. ● Establish the volume of each aliquot
● Exchange transfusion is done by the push pull technique through the umbilical
vein
● After exchange transfusion,phototherapy is continued and bilirubin lebels are
measured every 12 hours.
● Complications – metabolic acidosis, electrolyte abnormalities, hypoglycemia,
hypocalcemia, thrombocytopenia, volume overload, arrythmia, infection,
GVHD and death

33. 3.Intravenous immune globulin
● IVIG in infants with Rh or ABO isoimmunization can
significantly reduce the need for exchange transfusions.
● Now IVIG has replaced exchange transfusion as the
second-line treatment in infants with isoimmune
jaundice.
● IVIG 0.5-1 gm/kg/dose IV repeat 12 hourly

34. 4.Phenobarbital (Luminal)
Hyperbilirubinemia: 3-8 mg/kg/d PO/IV initially; may
increase up to 12 mg/kg/d Not to exceed IV administration
rate of 1 mg/kg/min or 30 mg/min for infants.It increases
the hepatic glucuronly transferase activity – criggler najar
syndrome,gilbert syndrome