Neonatal jaundice is the yellow discoloration of skin and mucous membranes due to high bilirubin levels in newborns. It is common, occurring in 30-50% of term and 80% of preterm infants. Jaundice can be physiological or pathological. Physiological jaundice is mild and resolves on its own, while pathological jaundice requires treatment. Treatment may include phototherapy, phenobarbital, exchange transfusion or metalloporphyrins depending on bilirubin levels. The goal of treatment is to prevent kernicterus, a toxic brain condition caused by high bilirubin levels.

1. Hardi Hussein Qader
Kirkuk university college of medicine
Neonatal Jaundice

2. Definition
• Yellow discoloration of the skin and the mucosa
due to accumulation of excess of bilirubin in the
tissue and plasma in neonates. (more than
5mg/dl).
30-50 % of term
newborn
And 80% of
preterm newborns.
2

3. Billirubin Metabolism

4. Special characteristic in neonates
•1.More billirubin produced
• Much more Hemolysis
• The life-length of hemolysis(70~80)

6. Special characteristic in neonates
•2.The low capability of albumin on
unconjugated billirubin transportation
• acid intoxication
• Less albumin in neonates

8. Special characteristic in neonates
•3.The low capability of heptatocyte
• Less Y protein and Z protein
• The primary development of Hepato-enzyme system
• Easy-broken hepato-enzyme system
• After-born, the blood glucose level is very low.

10. Special characteristic in neonates
• 4.High workload of the hepato-enteric circulation
• Less bacterial
• Low enzymatic activity in intestine
• High level of billirubin in
meconium

12. Jaundice
Physiological Pathological
12

13. NJ - 13
Physiological jaundice
• Characteristics
•Appears after 24 hours
•Maximum intensity by 4th-5th day in term & 7th day in
preterm
•Serum level less than 15 mg / dl
•Clinically not detectable after 14 days
•Disappears without any treatment
• Note: Baby should, however, be watched for
worsening jaundice.

14. NJ - 14
Why does physiological
jaundice develop?
•Increased bilirubin load.
•Defective uptake from plasma.
•Defective conjugation.
•Decreased excretion.
•Increased entero-hepatic circulation.

15. NJ - 15
Pathological jaundice
•Appears within 24 hours of age
•Increase of bilirubin > 5 mg / dl / day
•Serum bilirubin > 15 mg / dl
•Jaundice persisting after 14 days
•Stool clay / white colored and urine staining clothes
yellow
•Direct bilirubin> 2 mg / dl

18. The general symptom of neonatal
jaundice
• Yellow skin
• Yellow eyes(sclera)
• Sleepiness
• Poor feeding in infants
• Brown urine
• Fever
• High-pitch cry
• Vomiting

19. Grading of extent of jaundice 1
Area of body Billirubin levels
mg/dl (*17=umol)
Face 4-8
Upper trunk 5-12
Lower trunk & thighs 8-16
Arms and lower legs 11-18
Palms & soles > 15

20. Grading of extent of jaundice 2

21. Breast feeding jaundice
• In exclusively breast feed infants
• Appears at 24-48 hrs of age
• Peaks by 5-15 days
• Disappears by 3rd week
• Its related to inadequate B.F
• T/t:Proper & adequate B.F

22. Breast milk jaundice
• In 2-4 % EBF babies
• SBr>10mg/dl beyond 3rd-4th week
• Should be differentiated from Hemolytic jaundice, hypothyroidism,
G6PD def
• T/t: Some babies may require PT
Continue breast feeding
Usually declines over a period of time

24. Hemolytic disease of newborn
This condition occurs
when there is an
incompatibility between
the blood types of the
mother and baby.

25. Placental barrier
• ..

26. The blood types(A, B, O, AB)
• Although it is not as common (especially in a first pregnancy), a
similar problem of incompatibility may happen between the blood
types (A, B, O, AB) of the mother and baby in the following situations:

27. The blood types(A, B, O, AB)

28. The blood types (Rh)

29. Kernictrus (Bilirubin Encephalopathy)
• Lipid-soluble, unconjugated, bilirubin fraction is toxic to the
developing central nervous system
• indirect bilirubin is deposited in brain cells and disrupts neuronal
metabolism and function, especially in the basal ganglia.
• Indirect bilirubin may cross the blood-brain barrier because of its lipid
solubility.
• disruption of the BBB permits entry of a bilirubin-albumin or free
bilirubin–fatty acid complex.

30. Risk factors
• in term infants when bilirubin levels 20 to 25 mg/dL, but the
incidence increases as serum bilirubin levels exceed 25 mg/dL
• Less than 20 mg/dl in presence of sepsis, meningitis, hemolysis,
asphyxia, hypoxia, hypothermia, hypoglycemia, bilirubin-displacing
drugs (sulfa drugs), and prematurity.
• hemolysis, jaundice noted within 24 hours of birth
• delayed diagnosis of hyperbilirubinemia.
• Kernicterus has developed in extremely immature infants weighing
less than 1000 g when bilirubin levels are less than 10 mg/dL because
of a more permeable blood-brain barrier associated with prematurity.

31. • The earliest clinical manifestations of kernicterus are
• lethargy,
• hypotonia,
• irritability,
• poor Moro response,
• and poor feeding.
• A high-pitched cry and emesis also may be present.
• Early signs are noted after day 4 of life.
• Later signs include bulging fontanelle, opisthotonic posturing, pulmonary
hemorrhage, fever, hypertonicity, paralysis of upward gaze, and seizures.

32. Outcome :
• Infants with severe cases of kernicterus die in the neonatal period.
• Spasticity resolves in surviving infants, who may manifest later nerve
deafness,
• choreoathetoid cerebral palsy,
• mental retardation,
• enamel dysplasia, and discoloration of teeth as permanent sequelae.

33. Prevention:
• avoiding excessively high indirect bilirubin levels and by avoiding
conditions or drugs that may displace bilirubin from albumin.
• Early signs of kernicterus occasionally may be reversed by
immediately instituting an exchange transfusion

34. Medical Management
Phototherapy
Phenobarbital
Therapy
Metalloporphyrins
Exchange
Transfusion
34

35. Phototherapy
• When bilirubin > 12 %
• Discontinued when
level fallen > 2mg/dl of
previous.
35

36. TransBilirubin CisBilirubinisomer + Lumibilirubin
By Photoisomerisation
Excreted in the bile & Urine without Conjugation.
36

37. 6-8 daylight tubes are mounted on a stand and
all electrical outlets are well grounded.
At 425- to 475-nm wavelength band
Technique
37

38. Baby is placed naked 45 cm away from the tube lights in a
crib or incubator.
Eyes are covered with eye-patches to prevent damage to
the retina by the bright lights; gonads should also be
covered.
Phototherapy is switched on.
38

39. Baby is turned every two hours or after each feed.
Temperature is monitored every two to four hours.
Weight is taken at least once a day.
More frequent breastfeeding.
Urine frequency is monitored daily.
Serum bilirubin is monitored at least every 12 hours.
Phototherapy is discontinued if two serum bilirubin
values are < 10 mg/dl.
39

40. Contraindication :
Liver disease or obstructive jaundice.
Complications :
Watery diarrhoea
Skin rashes
Dehydration
Bronze baby syndrome
Retinal damage
40

41. Side effects of phototherapy
41
•Increased insensible water loss: Frequent Breast feeding.
•Loose green stools: weigh often and compensate with
breast milk.
•Skin rashes: Harmless, no need to discontinue
phototherapy.
•Bronze baby syndrome: occurs if baby has conjugated
hyperbilirubinemia. If so, discontinue phototherapy.
•Hypo or hyperthermia: monitor temperature frequently.

42. 42

43. Phenobarbital Therapy
ligandin in liver
Induces hepatic enzymes
billirubin conjugation & excretion
Dose: 10mg/kg Day 1 (loading dose)
5-8 mg/kg/day 4 days (maint. dose)
Or to Mother 2 weeks prior delivery.
Dose: 90 mg/day.
43

44. Metalloporphyrins
bilirubin by inhibiting heme oxygenase
Tin & Zinc are currently used.
44

45. Exchange transfusion
45

46. Indications:
Rise of bilirubin >1mg/dl/hour
To improve anemia & CCF
Sr. Bilirubin > 20mg/dl in first 24 hrs
Cord hemoglobin is < 12mg/dl & bilirubin is > 5mg/dl
46

47. The procedure involves the incremental removal of the
patient's blood and simultaneous replacement with
fresh donor blood, saline or plasma.
47

48. • The patient’s blood is slowly drawn out
• And an equal amount of fresh, prewarmed blood,
plasma or physiologic saline is transfused.
• The cycle is repeated until a predetermined volume of
blood has been replaced.
48

49. Risk and Complications
• Cardiac and respiratory disturbances
• Shock due to bleeding or inadequate replacement of
blood
• Infection
• Clot formation
• Rare but severe complications include: air embolism,
portal hypertension and necrotizing enterocolitis
49