This document provides an overview of neonatal jaundice, including its definition, clinical features, causes, complications, investigations, and management. Some key points include: - Jaundice is a common condition in newborns caused by accumulation of bilirubin in the skin. - It results from the normal breakdown of red blood cells in combination with the immature liver's ability to process bilirubin in newborns. - If left untreated, extremely high bilirubin levels can cause brain damage (kernicterus). - Treatment involves phototherapy or exchange transfusions in severe cases to lower bilirubin levels. - Causes of jaundice include physiological causes or

1. D R M A N O R I G A M A G E
( M B B S M D D C H M R C P C H )
S E N I O R L E C T U R E R I N P A E D I A T R I C S
F A C U L T Y O F M E D I C A L S C I E N C E S
U N I V E R S I T Y O F S R I J A Y E A R D E N E P U R A
S R I L A N K A
NEONATAL JAUNDICE

2. Contents
 Definition
 Clinical features
 Causes
 Complications
 Investigation
 Management

3. What is Jaundice?
 Yellow color discoloration of the skin and sclera of
newborn babies that results from accumulation of
bilirubin in the skin and mucous membranes.
 New born appears jaundiced when serum bilirubin is
more than 7mg/dl

4. What is Bilirubin?
 A breakdown product of RBC
 Produces un conjugated (indirect) bilirubin bound to
albumin
 This metabolized in the liver to produce the
conjugated bilirubin (direct)
 Which passes through the gut and excreted in stools
 And a portion of it enter the enterohepatic
circulation

5. Bilirubin catabolism
 Image

6. Overview of Neonatal Jaundice
 A common condition requiring medical attention in
newborns.
 60% of term and 80% of preterm babies develop
jaundice in the first week of life
 10% of breastfed babies are jaundiced at first month
of age

7. Why Newborns are susceptible for Jaundice?
 Their RBC has a shorter life span than the adult’s
 Their RBC concentration is high as an adaptation to
relatively hypoxic intrauterine life
 Hepatic enzyme immaturity for bilirubin conjugation
 Increased enterohepatic circulation due to lack of
intestinal flora

8.  Jaundice first appears between 24-72 hours of age
 Maximum intensity is seen on 4th to 5th day in a term
and 7th day in a preterm neonates
 Does not exceed 15mg/dl (255μmol/l)
 Clinically undetectable after 14 days in term baby
 It is a diagnosis by exclusion
Features of Physiological jaundice

9. Factors that Exacerbate Jaundice In the
Newborns
 Polycythemia
- Delayed cord clamping
- Maternofetal transfusion
- Recipient of twin – twin transfusion
 Extravasated blood
- Bruising
- Birth trauma
- Internal haemorrhage
 Delayed passage of meconium
 Swallowed blood
 Hypocaloric feed intake
 Dehydration
 Breastfeeding
 Prematurity

10. Features of Pathological Jaundice
 Clinical jaundice within 24 hrs of life
 Total serum bilirubin >15mg/dl after 24hrs of life
 Total serum bilirubin (TSB) increasing by
>5mg/dl/day or 0.5mg/dl/hr
 Conjugated bilirubin >20% of TSB
 Clinical jaundice persisting more than 2 weeks in a
term or more than 3 weeks in a preterm neonate.

11. Causes of Jaundice

12. Early Onset Jaundice
 Jaundice within the first 24 hours is commonly
result from significant hemolysis. This is a neonatal
emergency and a serum Bilirubin measurement
should be obtained within 2 hours
 Haemolytic disease of the newborn – Rh, ABO,
Minor blood group incompatibility.

13. Late Onset Jaundice
 Jaundice occurring at 2 days to 2 weeks

14. *From
illustrated
text book of
paediatrics

15. Identification of a new born with risk factors for
Bilirubin encephalopathy
 Gestational age less than 38 weeks
 A previous history with neonatal jaundice requiring
phototherapy
 Mother’s intention to breast feed exclusively
 Visible jaundice in the first 24 hours of life

16. Kernicterus
 Encephalopathy resulting from deposition of
bilirubin in brain stem, hippocampus, cerebellum
and brainstem nuclei (globus pallidus and sub
thalamic nuclei )

17. Features of Acute bilirubin Encephalopathy
 Hypotonia
 Lethargy
 Poor feeding
 Irritability
 Hypertonia of extensor muscles
 Opisthotonos
 Respiratory distress
 Shrill high pitched cry
 Apnoea
 Loss of moro reflex
 Seizures
 Coma

18. Long term Sequalae of bilirubin Encephalopathy
 Extrapyramidal disturbances
 High frequency sensorineural hearing disturbances
 Upward gaze palsy
 Athetoid cerebral palsy

19. Assessing the levels of serum bilirubin
 Visual inspection
 Transcutaneous Bilirubinometry
 Invasive blood sampling

20. Visual Inspection
• Jaundice restricted
to the face and trunk
– TSB <12mg/dl
• On hands and feet
– TSB > 15 mg/dl

21. Problems encountered in visual inspection
 Difficult to detect in preterm infants
 Can be missed in dark skinned babies
 Unreliable under artificial light
 Cease to use after initiating phototherapy
 Unable to asses the severity
 Accuracy is not improved by the assessment of the
Cephalo caudal progression of dermal jaundice

22. It is essential to estimate the bilirubin
level whenever a baby is visibly
jaundiced

23. Transcutaneous bilirubinometry
 Measured in the skin of forehead or overlying the
sternum
 Non invasive
 Inaccurate for levels
more than 250 micromol/l

24. New developments…
 “ BiliCam ” - application used via a smartphone
camera to assess the severity by a photograph

25. Invasive blood sampling
 By the use of Bilirubinometer by direct spectrometry
 Plotted in threshold graphs appropriate for the
gestational age to decide on the treatment

26. Investigations of jaundice in a newborn
Early onset jaundice
 Blood group and DAT
 Haemtocrit and FBC
 Blood picture
 Infection screen if indicated
 serology for congenital infections
 Urine for CMV culture
 Stool for virology
 G-6 PD screen
 Red cell enzyme studies

27. Prolonged Jaundice
 Total and conjugated bilirubin
 Thyroid profile
 Urine culture
 Urine for reducing substances
 Liver function tests
 Alpha-1 antitrypsin assay and phenotype
 Cystic fibrosis DNA screen
 Immuno -Reactive trypsin
 plasma cortisol level
 Serum amino acid level

28. Management
 Starts with prevention
 Support to initiate early feeding pattern
 Phototherapy
 Pharmacological agents – high dose IVIG to
suppress haemolysis
 Exchange transfusion

29. Phototherapy

30. Types
 Single phototherapy
 Double phototherapy
 Triple phototherapy

31. Optimal use of Phototherapy
 Efficacy of phototherapy depends on the:
- Dose – 25 -30 µW/cm³/nm
- Wavelength of light – blue light in 450 nm
- Proportion of the infant’s surface area

32.  Convenient and safe means of lowering serum
bilirubin
 Only effective as bilirubin enters the skin at serum
levels more than 80µmol/l
 Converts bilirubin to water soluble photo isomers
like Lumirubin thus excreted via urine
 Maximal effect is during first 24-48 hours of use
 In the absence of hemolysis reduce serum bilirubin
by 25% to 50%

33. Checking the response of Phototherapy..
 After starting phototherapy SBR checked 4- 6 hourly
until SBR is stable or falling
 And thereafter every 6- 12 hourly
 When SBR has fallen to more than 50µmol/l below
the phototherapy threshold, single phototherapy
should be stopped
 SBR checked for rebound after 12 – 18 hours

34. Cautions and Requirements during Phototherapy
 Individual assessment of fluid requirement
 Good thermoregulation
 Monitoring of stool frequency and urine output
 Eyes of the babies should be covered to avoid retinal
damage

35. Indications for multiple phototherapy
 SBR is within 50µmol/l below the threshold for
which the exchange transfusion is needed
 SBR is rising rapidly more than 8.5µmol/l/hour
despite single phototherapy

36. Biliblanket
Fibre- optic pads with
LED an effective way of
delivering phototherapy

38. Complications of phototherapy
 Diarrhea- as a result of irritant effect of photo
isomers on the bowel wall
 Increased fluid loss via the skin
 Temperature instability
 Erythematous rashes
 Tanning
 Bronze baby syndrome

39. Pharmacological agents
 Treatment with high dose IVIG for HDFN and ABO
iso -immunization reduces the need for exchange
transfusion
 Dosage 0.5 g/kg over 2- 4 hours

40. Exchange transfusion
 Double volume exchange transfusion (2×80ml/kg)
 Blood cross matched with mothers serum and babies
blood
 Indications
 Infants who fails to respond to optimal phototherapy
 Signs and symptoms of acute bilirubin encephalopathy

41. Investigations prior to ET
 Haemoglobin
 Reticulocyte count
 Blood picture for evidence of haemolysis
 Blood group – mother and baby
 Direct Coomb’s test
 SBR

42.  Umbilical vessels are the preferred access
 Use blood less than 5 days old
 Use acid citrate dextrose (ACD), or citrate phosphate
dextrose (CPD) as the anticoagulant
 Electrolytes, blood gases, vital sighs should be
monitored during the transfusion

43. o During exchange transfusion do not:
o stop continuous multiple phototherapy
o Perform single volume exchange
o Use albumin priming
o Routinely administer intravenous calcium
 Following exchange transfusion
o Maintain continuous multiple phototherapy
o Measure serum bilirubin level within 2 hours and
manage according to the threshold tables

44. Complications of Exchange transfusion
Exchange transfusion carries significant mortality(0.3%) and
morbidity(5%)
Some common complications are;
 Thrombocytopenia
 Hypocalcaemia
 Hypotension
 Venous thrombosis
 Hypokalemia
 Hypoglycemia
 Catheter malfunctions

45. References
 Management of neonatal jaundice: N Kevin Ives -
Journal of Paediatric and child health 25:6 June
2016
 National guidelines for new born care- volume 2
 NICE guidelines on Neonatal Jaundice- 2010
 Illustrated textbook of Paediatrics 5th Edition