MY NAME IS DR.M.SUDARSHAN REDDY,DNB(PAEDS) POSTGRADUATE TRAINEE,HOWRAH GENERAL HOSPITAL,HOWRAH,WEST-BENGAL.

1. NeoNatal JauNdice
DR.M.S.REDDY,
DNB Pediatrics,
HGH,HOWRAH,

2. Neonatal Jaundice
• Objectives:
• Define hyperbilirubinemia.
• Differentiate between physiological and
pathological jaundice.
• Causes of hyperbilirubinemia.
• Discuss the pathophysiology of hyperbilirubinemia.
• Describe the most dangerous complication of
hyperbilirubinemia.
• Therapeutic management.
• Design plan of care for baby has
hyperbilirubinemia.

3. (Hyperbilirubinemia)
• Definition: Hyperbilirubinemia refers to an
excessive level of bilirubin accumulation in the
blood and is characterized by yellowish
discoloration of the skin, sclerae, mucous
membranes and nails.
• Unconjugated bilirubin = Indirect bilirubin.
• Conjugated bilirubin = Direct bilirubin.

4. NJ - 4

5. Neonatal Jaundice
• Visible form of bilirubinemia
–Newborn skin >5 mg / dl
• Occurs in 60% of term and 80% of preterm
neonates
• However, significant jaundice occurs in 6 %
of term babies
• 6-10% require phototherapy/ other
therapeutic options.

6. Bilirubin metabolism
Hb → globin + haem
1g Hb = 34mg bilirubin
Non – heme source
1 mg / kg
Bilirubin
glucuronidase
Bilirubin
Bilirubin
Ligandin
(Y - acceptor)
Bil glucuronide
Intestine
Bil
glucuronide
Stercobilin
bacteria
β glucuronidase

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Bilirubin Production & Metabolism

8. Clinical assessment of jaundice
(Kramer’s staging)
Area of body Bilirubin levels
mg/dl (*17=umol)
Face Zone-1: 4-6
Upper trunk Zone-2: 6-8
Lower trunk & thighs 8-16
Arms and lower legs Zone-3: 8-12
Palms & soles Zone-4 :12-14
Zone-5 :>15

9. Causes of jaundice
Appearing within 24 hours of age
• Hemolytic disease of NB : Rh, ABO
• Infections: TORCH, malaria, bacterial
• Red cell enzymes defects like G6PD
deficiency,pyruvate kinase
• Administration of large amount of certain drugs
like vit k, sulfonamides.
• Hereditary spherocytosis.
• Crigler-najjar syndrome,lucey-driscoll syndrome….

10. Causes of jaundice
Appearing between 24-72 hours of life
• Physiological.
• Sepsis.
• Polycythemia.
• Intraventricular hemorrhage.
• Increased entero-hepatic circulation.
• Cretinism,breastfeeding,

11. Causes of jaundice
After 72 hours of age
• Sepsis
• Cephalhaematoma
• Neonatal hepatitis
• Extra-hepatic biliary atresia
• Breast milk jaundice
• Metabolic disorders such as galactosemia,
tyrosinemia,cystic fibrosis,gilbert syndrome.

12. Risk factors for jaundice
JAUNDICE
• J - jaundice within first 24 hrs of life
• A - a sibling who was jaundiced as neonate
• U - unrecognized hemolysis
• N – non-optimal sucking/nursing
• D - deficiency of G6PD
• I - infection
• C – cephalhematoma /bruising
• E - East Asian/North Indian

13. Physiological jaundice
Characteristics:
• Appears after 24-72 hours
• Maximum intensity by 3th-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. “Why does physiological jaundice
develop?”
• Increased bilirubin load.
• Defective uptake from plasma.
• Defective conjugation.
• Decreased excretion.
• Increased entero-hepatic circulation.

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

16. Causese of pathological jaundice
• Immaturity
• Hemolytic disease of the new born due to feto maternal
blood group incompatibility.
• Breast milk jaundice
• Hypothyroidism.
• Crigler-najjar syndrome
• Gilbert syndrome
• Malaria,concealed hemorrhage.
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17. 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

18. Dangers of hyperbilirubinemia
• Jaundice is the medical emergency.
• Uncojugated bilirubin causes bilirubin
encephalopathy or kernicterus.
• c/f of b.encephalopathy lethergy,hypotonia followed
by hypertonia ,refusal of feeds,shrillcry,setting sun
sign,fever,convulsions,coma,retrocollis and
opisthotonus .sluggish moro”s rflex.
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19. Kernicterus pathogenesis
• Conctroversial but interplay between three points
A.unconjugated bilirubin level >20mg/dl.
B.gestational maturity of infants.
C.integrity of blood-brain barrier.
-Cross the blood-brain barrier and gains access into the
neurons located in the basal
ganglia,hippocampus,auditory nuclei.
-serum bilirubin/protein more than 3.5 may be
associated with the brain damage.
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20. INVESTIGATIONS
• HISTORY OF SEVERE JAUNDICE OR EXCHANGE BLOOD
TRANSFUSION OR KERNICTERUS IN A PREVIOUS SIBLING.
• MOTHER O GROUP OR RH-NEGATIVE.
• ONSET OF JAUNDICE WITH IN 24 HOURS OR AFTER 72 HOURS
OF AGE.
• PERSISTENT OF JAUNDIC BEYOND 3 WEEKS.
• JAUNDICED INFANT WITH YELLOW-COLORED URINE OR CLAY
COLORED STOOLS.

21. Therapeutic Management
• AIM OF THERAPY: reduce level of serum bilirubin and
prevent bilirubin toxicity
• EXCHANGE BLOOD TRANSFUSION IS THE SINGLE MOST
EFFECTIVE AND RELIBLE METHOD OF TO LOWER THE
BILIRUBIN WHEN IT APPROCHES CRITICAL LEVELS.
• Supportive and therapeutic measures are useful to
prevent excess rise of serum bilirubin and reduce the
need for EBT

22. “PREDICTION OF HYPERBILIRUBINEMIA IN
HEALTHY NEAR-TERM AND TERM BABIES”
• Identify risk factors for development
hyperbilirubinemia.
• Routine screening for serum bilirubin levels.
• End-tidal corbon monoxide levels.
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23. PREVENTIVE AND SUPPORTIVE
MEASURES
• Adequate feeding.
• Aspiration of cephalhematoma.
• Treatment of sepsis and hepatitis.
• DRUGS:1.phenobarbitone 10mg/kg single
dose intramuscular or 5mg/kg/day in 2
divided doses orally for 3 days,2.clofibrate
50mg/kg single dose orally.
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24. MEASURES TO REDUCE SERUM
BILIRUBIN
• PHTOTOTHERAPY:
• EXCHANGE BLOOD TRANSFUSION:
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25. Phototheraphy
• Phototheraphy is a drug.
• Widely accepted and efective method.
• Wave lenth is 425-475nm.
• Photo-oxidation of bilirubin into water slouble
colorless forms of bilirubin like lumirubin.
• AAP recommends that phototheraphy should be
started,if serum bilirubin approaches the level of
18mg/dl.(15mg/dl if baby is having hemolysis or is
sick due to sepsis and perinatal distress factors).
• Phototheraphy is decline TSB@1-2mg/dl per 4-6
hours.
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26. Continue……
• Phototheraphy may be discontnued when TSB falls below
15mg/dl.
• Side effects :
• Passage of loose greeen stools because of lactose intolerance
and irritant effect of photocatabolites.
• Hyperthermia,irritability,and dehydration due to insensible
water loss may occur
• Infants with parenchymal liver disease with biliary obstruction
may develop peculiar bronze discoloration of skin due to
accumulation of one of the photoisomers designated as
lumirubin.
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27. Precautions…….
• Phototheraphy should be avoided in direct
hyperbilirubinemia and congenital porphyria.
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28. EXCHANGE BLOOD TRANSFUSION
• It is most effective method to reduce bilirubin levels.
• Serum bilirubin level of 20-25mg/dl at the age of 4-5 days.
• Early indications for exchange blood transfusion in infants
with Rh-haemolytic disease of the newborn.
• A.cord Hb% <10g/dl or haematocrit <30%.
• B.cord bilirubin of 5mg/dl or more.
• C.unconjugated serum bilirubin of 10mg/dl with in 24 hours
or 15mg/dl within 48 hours or rate of rise of >0.5 mg/dl /hr.
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29. INDICATIONS FOR EXCHANGE BLOOD
TRANSFUSION IN BABIES
BIRTH WEIGHT (G) TOTAL SERUM BILIRUBIN
(MG/DL)
NARMAL INFANTS HIGH RISK-INFANTS
UP TO 1000 10-12 8-10
1001-1250 12-14 10-12
1251-1500 14-16 12-14
1501-2000 16-18 14-16
2001-2500 18-20 16-18
>2500 20-22 18-20
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30. MANAGEMENT OF IDIOPATHIC HYPERBILIRUBINEMIA
IN HEALTHY TERM INFANTS
TOTAL SERUM
BILIRUBIN
AGE (HOURS) CONSIDER
PHOTOTHERAPHY
PHOTOTHERAPHY EBT
<24 - - -
25-48 >=12 >=15 >=20
49-72 >=15 >=18 >=25
>=72 >=17 >=20 >=25
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31. Babies under phototherapy
Baby under conventional
phototherapy
Baby under triple unit intense
phototherapy

32. Prognosis
• Early recognition and treatment of
hyperbilirubinemia prevents severe brain
damage.

33. PERSISTENT NEONATAL JAUNDICE
• PERSISTENCE OF JAUNDICE BEYOND 3 WEEKS MAY OCCUR
DUE TO UNCONJUGATED HYPERBILIRUBINEMIA OR
CHOLESTATIC JAUNDICE.
• DUE TO NON HEMOLYTIC UNCONJUGATED
HYPERBILIRUBINEMIA.
• COMMONEST CAUSE IS BREAST MILK JAUNDICE.
• DOWNS SYNDROME,GILBERTS
SYNDROME,HYPOTHYROIDISM,CRIGLER-NAJJAR SYNDROME,
………….
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34. CONTINUE………………
• Conjugated hyperbilirubinemia during early neonatal period is
rare.
• Occurs after 3weeks of neonatal age.
• Causes of conjugated hyperbilirubinemia.
• Idiopathic neonatal hepatitis.
• Inspissated bile syndrome.
• Infections
• Malformations.
• Metabolic disorders like galactocemia,tryosinemia,cystic
fibrosis…….
• Chromosomal causes and miscellaneous causes……………
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35. Nursing considerations of Hyperbilirubinemia
• Assessment:
 observing for evidence of
jaundice at regular intervals.
 Jaundice is common in
the first week of life and
may be missed in dark skinned
babies
Blanching the tip
of the nose

36. Approach to jaundiced baby
• Ascertain birth weight, gestation and postnatal age
• Ask when jaundice was first noticed
• Assess clinical condition (well or ill)
• Decide whether jaundice is physiological or
pathological
• Look for evidence of kernicterus* in deeply
jaundiced NB
*Lethargy and poor feeding, poor or absent Moro's, or
convulsions

37. The goals of planning
• Infant will receive appropriate therapy if
needed to reduce serum bilirubin levels.
o Infant will experience no complications from
therapy.
o Family will receive emotional support.

38. Thank You!