This document discusses neonatal jaundice and hyperbilirubinemia. It defines jaundice as a yellowish discoloration of the skin caused by an excessive level of bilirubin in the blood. It notes that jaundice is common in newborns, occurring in 60-70% of term babies and 80% of preterm babies. The document outlines the causes, types, risk factors, monitoring, and management of neonatal jaundice, with a focus on phototherapy as the main treatment for unconjugated hyperbilirubinemia.
Neonatal jaundice (hyperbilirubinemia) by Rajiv MavachiRajiv Mavachi
Jaundice is the most common condition that requires medical attention in newborns. The yellow coloration of the skin and sclera in newborns with jaundice is the result of accumulation of unconjugated bilirubin.
Neonatal jaundice (hyperbilirubinemia) by Rajiv MavachiRajiv Mavachi
Jaundice is the most common condition that requires medical attention in newborns. The yellow coloration of the skin and sclera in newborns with jaundice is the result of accumulation of unconjugated bilirubin.
Hello Guys,
This presentation talks about diagnosis and management of Antenatally detected hydronephrosis. We have discussed evidence based fetal hydronephrosis management including - antenatal followup schedule, fetal interventions, postnatal screening and follow up proforma, MCU, Functional renal scans, prophylactic antibiotics and available surgical management options.
This presentation is an overview of congenital cyanotic heart diseases, with a special discussion on Tetralogy of Fallot. We discuss the pathophysiology, clinical manifestations as well as the most updated management options for treating this condition. The topic ends with a few important complications seen in TOF patients. Hope you find it useful.
You can follow us on: Facebook page 'Neonatohub' (online academic platform) OR visit our YouTube channel 'Neonatohub' for more paediatric and neonatology presentations.
Hi Guys,
This presentation talks about Tuberculosis diagnosed in mother in the antenatal period, its treatment, implications on mother and fetus, the various protocols available currently regarding the neonatal management . Special focus being in major issues like breastmilk feeding, BCG, AKT prophylaxis, mother-child isolation.
Hope you find it useful.
P.S. - Please checkout my youtube channel - 'NEONATOHUB' & Facebook page 'Neonatohub' for lectures on neonatology.
Hello Guys,
This presentation consists of the updated guidelines under National tuberculosis elimination programme of India (MOHFW). The presentation includes case definitions and diagnostic algorithms for Pulmonary, Extrapulmonary and Drug resistant TB(MDR/ XDR TB) and the tratment protocols in pediatric cases.
Hope you find it useful.
This presentation is a simplified version of the various types of cardiac arrythmias seen in pediatric age groups. We have discussed supraventricular tachycarsias and prolonged QT syndrome in details here. Hope everyone finds it useful.
Hello guys,
Todays presentation aims at discussing the most common syndromic causes of short stature - Turners syndrome and Downs syndrome. We have discussed the Genetics, Phenotype and co-morbidities with their individual management strategies. I hope you find it uselful too.
This presentation discusses cranial hemorrhage in a newborn baby. We have included extracranial and intracranial bleed discussion in neonates. Intraventricular hemorrhage (IVH) is further discussed in details in terms of pathophysiology, management strategies and clinical studies related to it.
Hope this presentation is helpful for the knowledge and practice of medical students, pediatricians and neonatologists and helps in practical management of your NICU babies as well.
This presentation aims at helping the pediatric trainees and practitioners to brush up their knowledge in Immunization. The schedule is based on the Universal Immunisation Programme. I have tried to cover as much as possible in terms of individual vaccines and hope it is beneficial to the reader.
This presentation aims at helping the pediatric trainees and practitioners to brush up their knowledge in Immunization. The schedule is based on the Universal Immunisation Programme. I have tried to cover as much as possible in terms of individual vaccines and hope it is beneficial to the reader.
This presentation is a part 2/4 of series of presentation on Paediatric immunization.This presentation aims at helping the pediatric trainees and practitioners to brush up their knowledge in Immunization. The schedule is based on the Universal Immunisation Programme. I have tried to cover as much as possible in terms of individual vaccines and hope it is beneficial to the reader.
This presentation aims at helping the pediatric trainees and practitioners to brush up their knowledge in Immunization. The schedule is based on the Universal Immunisation Programme. I have tried to cover as much as possible in terms of individual vaccines and hope it is beneficial to the reader.
This presentation is aimed at giving the basic information of a neonate classification on basis of gestational age and the birth weight. Prematurity has been discussed in details. I have also included the growth charts that can be used for growth monitoring in term as well as preterm babies.
** This presentation is available in a video lecture format at my youtube channel - NeonatoHub. Do watch it for further understanding of the topic & subscribe to the channel.
This presentation aims at discussion of the pathophysiology , clinical presentation and management of the different types of intracranial bleeds in a neonate. Special emphasis has been laid on intraventricular hemorrhage. The germinal matrix bleed in a preterm is discussed in depth along with the various evidence based management protocols available. Radiological diagnosis of IVH in a preterm / term baby will be discussed in the upcoming presentations.
Hello guys, bringing to you the concept of golden hour of neonatology. As in trauma, the first hour of neonatal life is most precious and this ppt is an attempt to highlight a few key aspects of this resuscitative strategy in premature infants.
Thsi presentation is a sincere attempt to demonstrate the aseptic techniques needed to collect blood culture, urine culture, diagnostic lumbar puncture. Disscussion about the use of there modalities in neonatology practice and the ways to increase their sensitivity and specificity is done.
this presentation is also available in a video lecture format at my Youtube channel - "NeonatoHub". Hope you enjoy it more in that format.
https://www.youtube.com/watch?v=vZ71vymGVC8
This presentation deals with the basic physics of human ventillation. I have made an effort to clarify most of the venti lingo , so as to make way for further discussions on ventilator use. Hope it turns out to be helpful for you. Thank you.
Respiratory physiology & Respiratory Distress syndrome in a newborn.Sonali Paradhi Mhatre
Hi guys, This ppt shows the pathophysiology of pulmonary surfactant in newborn and respiratory distress syndrome. Main focus is towards management of RDS esp. exogenous surfactant administration. Your comments are welcome. Thank you.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
2. Defined as….
Hyperbilirubinemia refers to
an excessive level of
accumulated bilirubin in the
blood and is characterized by
jaundice.
Jaundice is the yellowish
discoloration of the skin,
sclerae, mucous membranes
and nails.
5. Neonatal Hyperbilirubinemia
When the rate of bilirubin production exceeds elimination, the end result is
hyperbilirubinemia.
Jaundice is the most common transitional finding in the newborn period,
occurring in 60-70% of term and approx. 80% in preterms.
Significant jaundice occurs in approx. 6 % of term babies
An elevation of Sr. Bilirubin conc. >2mgdl is found in virtually all newborns
in the first few days of life. Jaundice becomes clinically apparent when it
exceeds >5mgdl.
Physiologic ranges of TSB remain controversial as these levels are
affected by several factors like gestational age, birth wt, disease state,
level of hydration, nutritional status and ethnic background.
INdirect – Unconjugated
Direct - Conjugated
7. Classification of neonatal jaundice
• Appears after 24 hours
• Maximum intensity by 4th-5th day in term & 7th day in
preterm
• TSB levels within normal centiles for age in hours based on
normogram.
• Clinically not detectable after 14 days
• Disappears without any treatment.
Physiologic
jaundice
• Appears within 24 hours of age
• Increase of bilirubin > 5 mg / dl / day or at a rate of >0.2mg/dl/hr
• Serum bilirubin >95 percentile for age in hours based on
normogram.
• Jaundice persisting after 14 days in fullterm babies.
• Stool clay / white colored and urine staining clothes yellow
• Direct bilirubin> 2 mg / dl or >20% of TSB.
Pathologic
jaundice
8. Causes of physiologic jaundice
1. Increased bilirubin load due to physiologic increased RBC mass,
decreased RBC life span.
2. Decreased immediate postnatal bilirubin uptake due to reduced
ligandin activity.
3. Hepatic enzyme immaturity for bilirubin conjugation.
4. Increased enterohepatic circulation due to lack of intestinal flora,
greater proportion of β-glucoronidase.
9.
10. First 24 hrs
• Hemolytic disease of Newborn : Rh, ABO
• Infections: TORCH, malaria, bacterial
• G6PD deficiency
24 – 72 hrs
• Physiological
• Sepsis
• Polycythemia
• Intraventricular hemorrhage
• Increased entero-hepatic circulation secondary to feeding issues, hirschsprungs, etc.
> 72hrs
• Sepsis
• Cephalhaematoma
• Neonatal hepatitis
• Extra-hepatic biliary atresia
• Breast milk jaundice
• Metabolic disorders (IEM, G6PD).
Differential Diagnosis ( as per time of presentation) :
11. Causes of pathologic jaundice
1. Excessive Red cell hemolysis.
2. Defective conjugation of bilirubin.
3. Breast milk jaundice.
4. Metabolic and endocrine disorders.
5. Increased enterohepatic circulation.
6. Miscellaneous.
13. Monitoring
All newborns should be routinely assessed for jaundice.
Jaundice is visible when Sr. Bilirubin >5mg/dl.
Newborns to be observed for 72 hrs for jaundice appearance. In case of
discharge before 48hrs, Bilirubin risk factors and Hyperbilirubinemia risk
as per Normograms should be assessed and followup to be advised
accordingly.
A predischarge TSB or Transcutaneous bilirubin reading to be done if discharge
is before 72 hrs of life.
14. Risk factors:
Jaundice within first 24 hrs of life
A sibling who was jaundiced as neonate
Unrecognized hemolysis
Non-optimal sucking/nursing
Deficiency of G6PD, Pyruvate kinase.
Infection
Cephalhematoma /bruising
East Asian/North Indian
J
A
U
N
D
I
C
E
16. Gestational age 35 to <38wks + Hyperbili risk factors
Predischarge TcB / TSB
Bilirubin risk zones ( as per normogram)
High High intermediate) Low intermediate Low
Evaluate for Phototherapy,
TSB in 4 – 8 hrs.
(As per PT normogram)
Evaluate for phototherapy,
TcB / TSB in 4 – 24 hrs.
( As per PT noprmogram)
If Discharge <72 hrs,
Followup in 2 days
+ TcB / TSB
If discharge < 72hrs,
Followup in 2 days
AAP Screening guidelines - Type 1
17. Gestational age 35 to <38wks +no risk factors
OR
Gestational age >38 wks + hyperbili risk factors
Predischarge TcB / TSB
Bilirubin risk zones ( as per normogram)
High High intermediate) Low intermediate Low
Evaluate for Phototherapy,
TSB in 4 – 24 hrs.
(As per PT normogram)
Evaluate for phototherapy,
TcB / TSB within 24 hrs
( As per PT noprmogram)
If Discharge <72 hrs,
Followup in 2 days
If discharge < 72hrs,
Followup in 2 – 3 days
AAP Screening guidelines - Type 2
18. Gestational age > 38wks
+ No hyperbili risk factors
Predischarge TcB / TSB
Bilirubin risk zones ( as per normogram)
High High intermediate) Low intermediate Low
Evaluate for Phototherapy,
TSB in 4 – 24 hrs.
(As per PT normogram)
Follow up in 2 days
TSB / TcB on f/u
If Discharge <72 hrs,
Followup in 2 – 3 days
If discharge < 72hrs,
Followup as per age of
Discharge or SOS.
AAP Screening guidelines - Type 3
19. History
Gestational age
Age of onset of jaundice / duration.
H/O lethargy, irritability, convulsion, posturing, shrill cry.
Feeding history
Antenatal history of APH, PPROM, maternal DM, Thyroid disorders, antenatal infections.
Birth history of Birth asphyxia, resuscitation needed.
Family history of Jaundice, anaemia, splenectomy, metabolic disorder.
Previous sibling history , H/O neonatal deaths or morbidities in family.
?? Time of first stool passage, colour of stools, frequency of stools.
Urine colour and frequency.
20. Clinical assessment
** Colour of the skin
(to be checked in naked baby, natural light, non- yellow background, minimum blanching
over bony surfaces)
Severity of jaundice (Krammers staging of Jaundice)
Anemia, Signs of dehydration.
Hepatosplenomegaly
Complete neurological examination to look for s/o kernicterus
Special look for cephalhematoma, bruisings or bulging AF.
Abdominal mass, distension, ?Ascitis.
23. Transcutaneous bilirubinometer ( TcB)
TcB is a useful adjunct to TSB measurement
and routine employement of TcB can reduce
the need for blood sampling.
TcB can be used in infants of 35 wks or more
gestation & after 24 hrs of life.
TcB has a good correlation with TSB levels
but becomes unreliable once the TSB level
goes beyond 14 mg/dl.
Trends in TcB values 12 hrs apart have a
better predictive value than a single reading.
A TcB value more than 12 – 14 mg/dl needs
confirmation by TSB examination.
24. Indications for TSB measurement :
1. Jaundice in first 24 hour.
2. Beyond 24 hrs:
If visually assessed jaundice is likely to be more than 12 to 14mg/dL
(as beyond this TSB level, visual assessment becomes unreliable)
or
Approachingthe phototherapy range or beyond.
3. If you are unsure about visual assessment
4. During phototherapy, for monitoring progress and after phototherapy
to check for rebound in select cases (such as those with hemolytic jaundice)
26. Perform visual assessment every 12 hrly for initial 3-5 days.
This can be supplemented by TcB measurements.
Does the baby have serious jaundice???
Yes
Start
phototherapy
Measure the TSB levels to determine whether the
infant needs phototherapy or exchange transfusion.
Determine the cause of jaundice and
provide further management and followup
care
No
Does the infant have significant
jaundice to require TSB
measurement ??
Yes No
Continue observation
every 12 – 24 hrs for
next few days.
Approach to jaundice baby
37. Phototherapy
Phototherapy remains the mainstay in treatment
of neonatal hyperbilirubinemia.
It acts by photooxidation, photoisomerisation &
structural Isomerisation ( i.e.) converting insoluble
bilirubin into soluble isomers , which are easily
excreted in urine & faeces.
The phototherapy units available in market have
variety of light sources including flourescent
lamps, halogen bulbs, high intensity LED lamps &
fibreoptic light sources.
With easy availibility and low cost, CFL is most
commonly used in India. In last few years, LED use
has increased tremendously.
38. Phototherapy – Equipment specifications
Wavelength range = 460 – 490 nm.
(Practically used are white, blue lights)
Irradiance = minimum 30 μW/cm2/nm.
Distance of baby from unit = 30 to 45 cm.
(as per manufacturer instructions if specified)
Ambient room temperature = 26 – 28 degrees.
Plastic cover or shield to be placed before
phototherapy lams to avoid accidental injury in
case lamp breaks.
39. Phototherapy – Patient specifications
Expose maximum surface area of the baby.
Remove all clothes of the baby except diaper.
Apply a small eye patch. Make sure it does not
cover baby’s nostrills.
Avoid blocking the lights by any equipment like
warmer parts, large diaper, cap, dressing,
electrodes, etc.
If in an incubator, light should be perpendicular
to the baby.
40. Phototherapy – Patient specifications
Ensure adequate nutrition & hydration of the
baby.
Minimise interruption during feeds or
procedures.
There is no need to supplement breastfeed with
any other feeds or fluids during phototherapy.
Monitor temperature of the baby 2-4hrly, TSB
levels 12-24 hrly. Watch for rebound bilirubin
clinically.
Monitor baby’s hydration status esp. urine
output.
41. Phototherapy – side effects…..
•Increased insensible water loss / dehydration: 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. Exchange Transfusion
Exchange Transfusion is reserved for the most
severe forms of neonatal hyperbilirubinemia.
Double volume exchange transfusion has to be
performed if the TSB levels reach to age specific cut
offs for exchange transfusion or the neonate shows
signs of bilirubin encephalopathy irrespective of the
bilirubin levels.
Indications for DVET at birth for infants include :
1.) Cord bilirubin >4.5mg/dl.
2.) Cord Hb <11mg/dl
3.) Rate of bilirubin increase >1mg/dl/hr
4.) If Hb 11-13, rate of bili increase >0.5mg/dl/hr.
5.) Phototherapy fails to limit hyperbilirubinemia.
43. Exchange Transfusion
Type & Volume of blood for exchange transfusion
Sr. no Condition Type of blood
1 Rh Isoimmunization Rh negative and bld group ‘O’ or that of baby.
Cross matched with baby’s and mother’s blood.
2 ABO incompatibility Rh compatible & blood group ‘O’ (NOT THAT OF BABY)
Cross matched with baby’s and mothers blood.
3 Other conditions (G6PD
def, other hemolutic
conditions)
Baby’s group & Rh type.
Cross matched with mother and baby sample.
Volume of blood: Twice the blood volume of baby (total volume: 160 to 180 mL/kg)
Preferred preservative – CPD (citrate phosphate dextrose)
Blood should be < 72 hrs old (to ensure bld pH <7)
For hydrops fetalis, prefer fresh blood < 24 hrs old.
44. Exchange Transfusion
Assistant help - Maintain sterile field, monitor and assess
the infant , record the procedure and exchanged volumes.
Equipment needed - Radiant warmer/incubator,
pulseoximeter, resuscitation apparatus, UAC/UVC insertion
equipment, bivalves, NGT, Exchange transfusion circuit,
Blood for exchange to be warmed at room temperature.
Blood should be obtained for lab studies before and after
ET:
Total Serum bilirubin, calcium, sodium, potassium, chloride,
pH, pCO2,bicarb, Sr. glucose. Hemoglobin , platelet count,
WBC.
Blood culture is recommended after Exchange transfusion.
45. Exchange Transfusion - Procedure
Double volume exchange transfusion done
in hyperbilirubinemia in neonates.
Normal blood volume is 80ml/kg in fullterm baby.
Therefore, 160ml/kg of blood ( after blood grouping &
cross matching) will be needed for the procedure.
Procedure to be performed under complete aseptic precautions.
Baby placed in supine position.
Restraints can be given…. Snug but not tight.
Stomach decompression by nasogastric tube and left in situ.
Scrub and put on sterile gown and gloves.
Perform umbilical vein catheterisation and confirm position by
radiograph.
If isovolumetric double exchange to be done, umbilical artery
catheter to be inserted.
Have the unit of blood ready. Attach the bag of blood to the tubing and
stopcocks. According to the direction of the transfusion tray.
Check the orientation of the stopcock directions before starting the infusion and
withdrawl.
46. Exchange Transfusion - Procedure
Eastablish the volume of each aliquot.
Exchange transfusion can be done by the push –
and- pull technique through the umbilical vein.
The recommended duration is 1 hr.
After exchange transfusion , phototherapy is continued
and bilirubin levels are measured every 4 hrs.
Calcium gluconate , antibiotics are to be given
SOS (On individual basis)
Side effects : Hypoglycemia, Hypocalcemia,
hyperkalemia, Bleeding/coagulopathies,
Infections, late metabolic alkalosis.
Infant weight Aliquot (ml)
3 kg 20
2 – 3 kg 15
1 – 2 kg 10
850g – 1 kg 5
< 850 gm 1 - 3
47. Other Treatment modalities :
• Increases hepatic glucoronyltransferase activity & conjugation od bilirubin.
• Used to treat Criggler najjar , gilbert syndromes.
• Not effective as urgent treatment as it takes some time for effect.
• Sedation & neurologic side effects limits its use.
Phenobarbitone
• Tin (Sn) and zinc (Zn) are being used in trials.
• They work by decreaseing the production of bilirubin by competitive inhibition of heme
oxygenase.
• Their long term safety is still under study. Not yet approved by FDA.
Metal
metalloporphyrins
• This has been effective in infants with Rh & ABO hemolytic disease and reduces the
need for exchange transfusion.
• AAP recommends this in isoimmune hemolytic disease if TSB levels are rising despite
phototherapy or TSB levels are within 2-3mg/dl of exchange level.
• Dose is 500mg – 1gm/kg over 2 hrs, repeated in 12 hrs (only if necessary)
IVIG
• Can be given if albumin levels are low.Albumin
49. Kernicterus
Caused secondary to chronic bilirubin
encephalopathy.
Acute bilirubin encephalopathy may develop
during hazardous hyperbilirubinemia and
develop in chronic adverse neurodevelopmental
sequelae.
TETRAD of Kernicterus :
1. Choreoathetoid Cerebral Palsy.
2. High frequency central neural hearing loss.
3. Vertical gaze palsy.
4. Dental enamel hypoplasia.
50. Kernicterus (cont..)
Unconjugated Hyperbilirubinemia.
Bilirubin predilection to neurons & involvement of
basal ganglia, cochlea and oculomotor neuron.
Stages of Kernicterus :
STAGE 1 : decreased activity, poor sucking,
hypotonia, high pitched cry.
STAGE 2 : Stage 1 features + rigid extension of all 4
extremities, tight fisted posturing of arms, crossed
extension of legs, high pitched irritable cry.
Sometimes seizure, retrocolis, opisthotonus posture.
STAGE 3 : Hypertonia, retrocolis, opisthotonus, stupor,
coma.
51. Kernicterus – MRI findings
Abnormally high signal intensity on T1 weighted images of
basal ganglia , thalamus & internal capsule.
Similar, but less intense signal was seen on T2 weighted images
52.
53. Direct Jaundice
Defined as measure of direct reacting
bilirubin of >1mg/dl in TSB <5. OR more
than 20 % of the TSB levels.
Also known as Conjugated
hyperbilirubinemia.
It is a biochemical marker of cholestasis
& indicator of hepatobiliary dysfunction.
Always Pathological
57. Management
1.) Medical :
Special formulas (medium chain triglycerides)
Vitamin Supplements (Vit K, E, D, A)
Dietary restrictions (as per diagnosis)
2.) Pharmacological :
UDCA (Ursodeoxycholic acid)
Phenobarbitone
Cholestyramine
3.) Surgical : as per the diagnosis, SOS Liver transplantation.
58. AAP Guidelines
Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation.
Pediatrics. 2004; 114:297-316 (July issue)
Key elements of the recommendations provided by this guideline.
Clinicians should:
1. Promote and support successful breastfeeding.
2. Establish nursery protocols for the identification and evaluation of
hyperbilirubinemia.
3. Measure the total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) level
on infants jaundiced in the first 24 hours.
4. Recognize that visual estimation of the degree of jaundice can lead to errors,
particularly in darkly pigmented infants.
59. AAP Guidelines
5. Interpret all bilirubin levels according to the infant’s age in hours.
6. Recognize that infants at less than 38 weeks’ gestation, particularly those who
are breastfed, are at higher risk of developing hyperbilirubinemia and require
closer surveillance and monitoring.
7. Perform a systematic assessment on all infants before discharge for the risk of
severe hyperbilirubinemia.
8. Provide parents with written and verbal information about newborn jaundice.
9. Provide appropriate follow-up based on the time of discharge and the risk
assessment.
10. Treat newborns, when indicated, with phototherapy or exchange transfusion.