NEONATAL JAUNDICE IS MOST COMMON CAUSE OF MORBIDITY IN 1ST WEEK OF LIFE IT IS ALSO MOST COMMON CAUSE OF READMISSION AFTER DISCHARGE .THIS BEAUTIFUL SLIDE FOR NNJ.

1. NEONATAL JAUNDICE
DR MAHTAB
MBBS,DCH,DNB
HIMSR,NEW DELHI

2. INTRODUCTION
MOST COMMON MORBIDITY IN 1ST WEEK OF LIFE
OCCUR IN; 60% TERM,80% PRETERM
MOST COMMON CAUSE OF READMIASSON AFTER DISCHARGE
IN NEONATES JAUNDICE VISIBLE SKIN AND EYE >5-7MG/DL
IN ADULT >2MG/DL
MOST CASES JAUNDICE IS BENINGN AND NO INTERVENTION IS
REQUIRED.APPROX 5-10% HAVE SINGIFICANT JAUNDICE REQUIRED
TREATMENT TO LOWER S. BILIRUBIN LEVEL
HIGH LEVEL CARRY RISK OF NEUROLOGICAL IMPAIRMENT SO
REQUIRE T/T TO LOWER DOWN

3. 3 BASIC MECHANISM ;
1. INCREASED PRODUCTION FROM DEGRADATION OF RED CELL
2. DECREASE CLEARENCE BY IMMATURE HEPATIC MECHANISM
3. REABSORBTION BY ENTEROHEPATIC MECHANISM

6. TYPE OF BILIRUBIN
UNCONJUGATED BILIRUBIN CONJUGATED BILIRUBIN
BIND TO ALBUMIN CONJUGATED WITH
GLUCOURONIC ACID
FAT SOLUBLE WATER SOLUBLE
CAN CROSS BBB EXCREATED IN STOOL AND
URINE
TOXIN IN HIGH LEVEL TO BRAIN NOT TOXIC

7. PHYSIOLOGICAL VS PATHOLOGICAL JAUNDICE
PHYSIOLOGICAL IMMATURITY OF NEONATES TO HANDLE
INCREASED BILIRUBIN PRODUCTION,
IN TERM JAUNDICE APPEAR 24-72 HR OF LIFE TSB GOES PEAK
LEVEL 12-15MG/DL @ DAY 3 THAN FALL
IN PT PEAK LEVEL OCCUR ON 3-7 DAYS OF AGE CAN RISE
OVER 15MG/DL THAN FALL CAN TAKE WEEKS

8. PATHOLOGICAL JAUNDICE
PRESENCE OF ONE OR MORE OF FOLLOWING CONDITION
WOULD QUALIFY A NEONATES HAVE PATHOLOGICAL JAUNDICE
1. VISIBLE JAUNDICE ON DAY 1ST OF LIFE( >5)
2. PRESENCE OF JAUNDICE ARM AND LEG ON D2(121-13MG/DL)
3. YELLOW PALM AND SOLE ANYTIME
4. TSB INCREASES >.2MG/DL PER HR YA 5MG/DL IN 24 HR
5. SIGN OF ACUTE BILIRUBIN ENCEPHALOPATHY AND
KERNICTERUS
6. DIRECT BILIRUBIN >1.5-2MG/DL AT ANY TIME
7. CLINICAL JAUNDICE PERSISTINGBEYOND 2WK IN TERM AND 3
WK IN PRETERM

9. CAUSES OF PATHOLOGICAL JAUNDICE
HEMOLYSIS; ABO,RH,MINOR GROUP INCOMPATIBILITY,ENZYME
DEF EG G6PD DEFICIT,AIHA
DECREASED CONJUGATION DUE LIVER ENZYME IMMATURITY
INCREASE ENTEROHEPATIC CIRCULATION SUCH AS LACK OF
ADEQUATE FEEDING THAT INCLUDE INSUFFICIENT
BREASTFEEDING /INFANT NOT FEED DUE TO ILLNESS,GI
OBSTRUCTION
EXTRAVASATED BLOOD ;CEPHALHEMATOMA,EXTENSIVE
BRUISING ETC

10. VISUAL INSPECTION
EXAMINE BABY IN BRIGHT NATURAL LIGHT /ALT IN WHITE
FLUORESCENT LIGHT,WITH NO YELLOW BACKGROUND
NAKED BABY….EXAMINE BLANCHED SKIN AND GUMS AND
SCLERA
NOTE EXTENT OF JAUNDICE (KRAMER S LAW
FACE 5-7MG/DL
CHEST 8-10MG/DL
LOWE ABD AND THIGH 12-15MG/DL
SOLES/PALMS >15MG/DL

11. NEONATES AT HIGHER RISK OF JAUNDICE
<38 WK
PREVIOUS CHILD WITH SIGNIFICANT JAUNDICE
VISIBLE JAUNDICE IN FIRST 24 HR OF LIFE
AGE SPECEFIC TSB LEVEL BEING ABOVE >95TH CENTILE
INADEQUACY OF BREASTFEEDING COMMON CAUSE I.E
BREASTFEEDING JAUNDICE

12. MEASUREMENT OF SERUM BILIRUBIN
1. TRANSCUTANEOUS BILIRUBINOMETRY TcB
CAN USE >35 WEEK OR MORE GESTATION AFTER 24 HR OF
LIFE ,
TcB HAS A GOOD CPRRELATION WITH TSB AT LOWER LEVEL
BUT IT BECOME UNRELIABLE ONCE TSB LEVEL GOES
BEYOND 14MG/DL
2. BIOCHEMICAL ; HIGH PERFORMANCE LIQUED
CHROMATOGRAPHY(HPLC) GOLD STANDARD
TSB ESMITATION BY VANDENBERGH REACTION
3. MICRO METHOD OF TSB ESTIMATION; BASED ON
SPECTROPHOTOMETRY AND ESTIMATE TSB ON MICRO
BLOOD SAMPLE

14. LABORATORY TESTS
1. TOTAL AND DIRECT BILIRUBIN
2. BLOOD GROUP AND RH OF MOTHER AND BABY
3. HEMATOCRIT,RETICULOCYTE COUNT AND PERIPHERAL
SMEAR
4. G6PD ASSAY
5. COOMB TEST
6. SEPTIC SCREEN
7. LFT.TFT
8. TPORCH TITRE
9. LIVER SCAN WHEN CONJUGATED HYPERBILIRUBINEMIA
10.USG OF LIVER AND BILE DUCT IN CHOLESTASIS

15. LABORATORY DIAGNOSIS
LABORATORY FEATURE RH ABO
BLOOD TYPE OF MOTHER RH NEGATIVE O
BLOOD TYPE IN INFANT RH POSITIVE A OR B
ANEMIA MARKED MINIMAL
DCT POSITIVE NEGATIVE
ICT POSITIVE USUALLY POSITIVE

16. MANAGEMENT
1. PHOTOTHERAPY
2. IVIG
3. EXCHANGE TRANSFUSION
4. DRUGS

20. PHOTOTHERAPY
MAINSTAY OF TREATING HYPERBINEMIA
BLUE GREEN LIGHT 460-490NM ,BILIRUBIN MOLECULE
ISOMERISE TO HARMLESS FORM
CFL,HALOGEN BULB,HIGH INTENSITY LIGHT EMITTING
DIODE(LED) AND FIBROOPTIC SOURCES.
CFL MOST COMMONLY DUE LOW COST AND EASY AVABIELITY

21. LED HAS ADVANTAGE OF LONG LIFE (50,000 HR) AND CAPABLE OF
DELIVER HIGHER IRRADIANCE THAN CFL LAMPS
EXPOSE MAXIMAL SURFACE AREA OF BABY ( AVOIAD BLOCKING OF
LIGHT BY ANY EQUIPMENT,LARGE DIAPER OR EYE
PATCHES,CAP,HAT ,TAPE
MAKE SURE LIGHT FALL ON BABY PERPENDICULARLY IF THE BABY
IN INCUBATOR
MINIMUM INTERRUPTION OF PT DURING FEEDING SESSION OR
PROCEDURE
KEEP THE DISTANCE BABY AND LIGHT 30-45CM

22. PRINCIPLE OF PHOTOTHERAPY
NATIVE BILIRUBIN (WATER INSOLUBLE)
PHOTO ISOMER OF BILIRUBIN (WATER SOLUBLE) STRUCTURAL ISOMERISM I.E LUMIRUBIN
URINE
2. CONFIGURATIONAL PHOTO ISOMERISM Z..E
3. PHOTO OXIDATION OF BILIRUBIN INTO WATER SOLUBLE AND LESS LIPOPHILIC
COLORLESS FORM OF BILIRUBIN

23. PHOTOTHERAPY TECHNIQUE
• PERFORM HAND WASH
• PLACE BABY NAKED IN CRADLE OR INCUBATOR
• FIX EYE SHADES
• KEEP BABY ATLEAST 45 CM FROM LIGHT
• START PHOTOTHERAPY
• FREQUENT EXTRA FEED 2 HRLY
• TURN BABY AFTER EACH FEED
• TEMP RECORD 2-4 HRLY
• WEIGHT RECORD DAILY
• MONITOR URINE FREQUENTLY
• MONITOR BILIRUBIN LEVEL

24. SE OF PHOTOTHERAPY
1. INCREASED INSENSABLE WATER LOSS
2. LOOSE STOOL
3. SKIN RASH
4. BRONZE BABY SYNDROME
5. HYPERTHERMIA
6. HYPOCALCEMIA

25. MONITORING AND STOPPING PHOTOTHERAPY
MONITOR TEMP OF BABY EVERY 2-4 HR,MEASURE TSB EVERY
12-24HR
DISCONTINUE PT ONCE 2 VALUE 12 HR APART FALL BELOW
CURRENT AGE SPECIFIC CUT OFFS
MONITOR REBOUND BILIRUBIN RISE WITHIN 24 HR AFTER
STOPPING PT
ROLE OF SUNLIGHT
NOT HELP IN TREATMENT
A/W RISK OF SUNBURN AND THEREFORE SHOULD BE AVOIDED

26. EXCHANGE TRANSFUSION
DVET SHOULD BE PERFORM IF TSB LEVEL REACH TO AGE SPECEFIC
CUT-OFF VALUE FOR EXCHANGE TRANSFUSION OR INFANT SHOW
SIGN OF ENCEPHALOPATHY IRRESPECTIVE OF TSB LEVEL
INDICATION @ BIRTH----- CORD TSB IS ≥ 5 OR CORD HB≤ 10G/DL
DONE BY PULL AND PUSH TECHNIQUE VIA UMBILICUS UMBILICAL
CATHETOR
VOLUME OF BLOOD 2X VOLUME OF BLOOD OF BABY 160-180ML/KG
TO PREPARE BLOOD FOR DVET 2/3 OF PRBC AND 1/3 OF
P PLASMA

28. OTHER
IVIG REDUCE HEMOLYSIS SO REDUCE JAUNDICE IN ABO/RH INCMPATABILITY
REDUCE SIGNIFICANTLY NEED OF EXCHANGE TRANSFUSION
NOW IVIG HAS REPLACED EXCHANGE TRANSFUSION AS THE SECOND LINE OF TREATMENT IN INFANT
WITH ISOIMMUNE JAUNDICE
DOSE 1G/KG/DOSE IV
IV HYDRATION; IN SEVERE HYPERBILIRUBINEMIA AND EVIDENCE OF DEHYDRATION EG WT LOSS AN EXTRA
FLUID 50ML/KG N/3 OVER 8 HR DECREASE NEED OF ET
PHENOBARBITAL (LUMINAL)/CLOFIBRATE OR STEROIDS NO PROVEN EVIDENCE OF BENEFIT SO SHOULD
NOT BE EMPLOYED

29. THANK YOU HIMSR
SOURCE NELSON
CLOHERTY
AIIMS NEONATALOGY PROTOCOL