Neonatal jaundice pediatrics

1. NEONATAL JAUNDICE
AMY TREESA JAMES P
63

2. INTRODUCTION
 Important problem in the first week of life.
 Dermal staining- yellow discoloration, cephalocaudal
direction.
 High bilirubin levels- toxic to central nervous system &
cause neurological impairment.
 Visual assessment- every 12hr during initial 3 to 5 days of
life, can be supplemented with TcB (Transcutaneous
bilirubinometry).
 60% of term newborns-visibly jaundiced in 1st
week of life
but mostly benign.
 5-10%-phototherapy or other therapeutic options.

3. PHYSIOLOGICAL VS
PATHOLOGICAL JAUNDICE
 Physiological Jaundice:
 Physiological immaturity to handle increased bilirubin
production.
 Visible jaundice-appears between 24-72 hrs.
 TSB peaks in 3 days, then falls in term neonates.
 Pathological Jaundice:
 Appears within first 24 hrs of life.
 Elevation of TSB level, exceeds 5mg/dL on first day, 10 mg/dL
in second day, 15 mg/dL thereafter.
 Clinical jaundice-beyond 3 weeks.
 Conjugated bilirubin.

4. CAUSES
 Hemolytic:
• Rh/ABO incompatibility
• G6PD deficiency
• Thalassemia
• Hereditary spherocytosis
 Non-Hemolytic:
• Prematurity
• Extravasated blood
• Inadequate feeding
• Polycythemia
• Idiopathic
• Breast milk jaundice

5. CAUSES
 <24 hrs: Pathological
• Hemolytic disease
• Infections
 24-72 hrs
• Physiological
• Sepsis
• Polycythemia
• Concealed hemorrhages
• Increased enterohepatic
circulation
 >72 hrs
• Sepsis
• Neonatal hepatitis
• Extrahepatic biliary atresia
• Breastmilk jaundice
• Metabolic disorders

6. COMMON CAUSES OF JAUNDICE DEPENDING
UPON DAY OF APPEARANCE
DAY
 DAY 1
 DAY 2
 AFTER DAY 3
 AFTER THE FIRST WEEK
TYPE OF JAUNDICE
 BLOOD GROUP
INCOMPATIBILITY
 PHYSIOLOGICAL JAUNDICE
 SEPSIS
 BREAST MILK JAUNDICE,
HYPOTHYROIDISM,
NEONATAL HEPATITIS

7. PHYSIOLOGICAL JAUNDICE
 Over two thirds of all normal newborns.
 After 1st
day of life-accumulation of unconjugated bilirubin.
 Peaks in 3-4 days and disappears in 7-10 days.
 CAUSES
 Increased bilirubin production.
 Immaturity of hepatic conjugation.
 Delayed establishment of effective breastfeeding.
 Defective uptake and excretion of bilirubin.
 TREATMENT
 No need of any specific treatment.

9. PRESENCE OF ANY OF FOLLOWING
SIGNS-PATHOLOGICAL JAUNDICE
 Clinical jaundice- before 24 hrs of age
 Serum bilirubin rise->5mg/dL/day
 Serum bilirubin rise->15mg/dL
 Clinical jaundice beyond 14 days of life
 Clay-/white colored stool and/or dark urine staining the clothes
yellow
 Direct bilirubin >2mg/dL at any time

10. BREASTFEEDING JAUNDICE
• Exclusively breastfed- different
pattern of physiological
jaundice than artificially fed
babies.
• Inadequate breastfeeding.
• Appears: 24-72 hrs.
• Peaks: 5-15 days.
• Disappears: third week of life.
• 1/3rd
cases: mild jaundice in 3rd
week- persists into 2nd/3rd
month of life.
• Ensure optimum breastfeeding.
BREASTMILK JAUNDICE
• 2-4% cases-jaundice in excess
of 10 mg/dL beyond 3rd
/4th
week of life.
• Milk contain inhibitors of
conjugation(Pregnanediol, non
esterified long chain fatty acids)
• Diagnosis, if this is
unconjugated(mild
unconjugated
hyperbilirubinemia).
• Rule out other causes.
• Continue breastfeeding.
• Needs no treatment rarely
phototherapy.

11. RISK FACTORS FOR SEVERE HYPERBILIRUBINEMIA
 Jaundice observed-first 24hrs
 Blood group incompatibility
 Gestational age 35-36 weeks
 Previous sibling received phototherapy
 Cephalohematoma
 Inadequate breastfeeding
 East Asian race

12. DANGERS OF HYPERBILIRUBINEMIA
 KERNICTERUS
 Unconjugated bilirubin can cross the immature Blood Brain Barrier
[BBB].
 SYMPTOMS
• Lethargy
• Loss of Moro reflex
• Poor feeding
Intracranial involvement
• High pitched cry
• Bulging fontanel
• Seizures
• Opisthotonos
If Infant survives
• Choreoathetoid cerebral palsy
• Mental retardation
• Paralysis of upward gaze
• High-frequency hearing impairment

13. CLINICAL EVALUATION

14. APPROACH-AN INFANT WITH JAUNDICE
visual assessment every 12 hrs, first 3-5 days ; TRANSCUTANEOUS IF AVAILABLE.
STEP1: Does baby
have serious
jaundice?
Yes
Start phototherapy
Measure S.bilirubin:
Phototherapy/Exchange
transfusion.
STEP3: Determine cause of
jaundice- support and follow-up.
No
STEP2: Does the baby have significant jaundice to require
serum bilirubin measurement?
Yes No
Routine screening every 12 hr.

15. INVESTIGATIONS
 FIRST LINE
• Total serum bilirubin.
• Blood groups of mother and baby.
• Peripheral smear: Evidence of hemolysis.
 SECOND LINE
• Direct Coombs test: Antibody coating on fetal RBC.
• Hematocrit: Decreased in hemolysis.
• Reticulocyte count: Increased in hemolysis
• G6PD levels.
• Others: Sepsis screen, thyroid function test, rule out
other genetic enzyme deficiencies.

16. CLINICAL ESTIMATION
KRAMER’S DERMAL STAINING OF
BILIRUBIN:
• Examine in good daylight.
• Cephalocaudal direction.
• Blanch with digital pressure -
skin of forehead, chest,
abdomen, thighs, legs, palms,
soles & underlying color of skin
and subcutaneous tissue
noted.
• Staining of palms and soles-
danger sign.

17.  According to dermal zone of staining- approximate TSB levels are:

18. CUT-OFFS FOR TREATMENT IN PRETERMS:
GESTATION
(COMPLETED WEEKS)
PHOTOTHERAPY
[TSB-mg/dL]
EXCHANGE
TRANSFUSION
[TSB-mg/dL]
<28 weeks 5-6 11-14
28-29 weeks 6-8 12-14
30-31 weeks 8-10 13-16
32-33 weeks 10-12 15-18
34 weeks 12-14 17-19

19. CLINICAL HISTORY
 Suggests Obstructive jaundice if
• Greenish-yellow jaundice
• Acholic(pale) stools
• High coloured urine
• Itching
 Suggests Haemolytic jaundice if
• Lemon yellow jaundice
• Yellow stools
• Normal coloured urine
• No itching

20. PROLONGED JAUNDICE
 Beyond 3 weeks(10mg/dL).
 COMMON CAUSES:
 Inadequate feeding
 Breast milk jaundice
 Extravasated blood
 Hemolytic disease
 G6PD deficiency
 Hypothyroidism
 IF THE BABY HAS DARK URINE OR SIGNIFICANT JAUNDICE, RULE OUT:
 Cholestasis
 Hemolysis, G6PD screen
 Hypothyroidism
 Urinary tract infection

21. MANAGEMENT

22. PHOTOTHERAPY
• Mainstay of treating
hyperbilirubinemia.
• Converts insoluble bilirubin
(unconjugated) into soluble isomers
that can be excreted in urine or
feces.
• Blue-green light (460-490 nm) of
high irradiance.
• Acts by several ways:
 Configurational isomerism.
 Structural isomerism.
 Photo oxidation.

24. TYPES OF PHOTOTHERAPY LIGHTS
 Fluorescent lamps of different colors and shapes(CFLs)
 Halogen bulbs
 High intensity LEDs (blue)-long life, high irradiance
 Fibro-optic light sources

25. PROCEDURE
 Ensure optimum room temperature: 25-28 degree Celsius.
 Keep the baby in a cot/ bassinet/ incubator/ radiant warmer.
 Remove all clothes of baby except diaper. Expose maximal surface
area of body. Avoid blocking of light by any equipment.
 Cover baby’s eyes with an eye patch.
 Keep the distance between baby and light 30-45 cms.
 Ensure optimum breastfeeding. Minimize interruption of
phototherapy during feeding sessions or procedures.
 Monitor temperature of baby every 2-4 hours.
 Measure TSB levels every 12-24 hrs.
 Discontinue once two TSB values 12 hours apart fall below current
age-specific cut offs.
 Monitor for rebound rise within 24 hrs after stopping
phototherapy.

26. ADVERSE EVENTS OF PHOTOTHERAPY
 Diarrhoea
 Rash
 Dehydration
 Hyperthermia
 Bronze baby

27. EXCHANGE TRANSFUSION
 Double Volume Exchange Transfusion(DVET) should be done if TSB
levels reach to age specific cut-off for ET or signs of bilirubin
encephalopathy is seen.
 INDICATIONS
 Cord bilirubin: 5mg/dL or more.
 Cord Hb is 10mg/dL or less.
 ET performed by pull and push technique through umbilical venous
route.
 Umbilical catheter should be inserted.

28. MEDICATIONS
 IV immunoglobulin-protecting sensitized red cells
from getting hemolysed.

29. FOLLOW-UP
 Serum bilirubin>20mg/dL
 Require ET
 BERA done at 3 months of age

30. PREVENTION
• Antenatal maternal blood grouping.
• Ensure adequate breast feeding.
• Parent education regarding danger signs.
• High-risk babies.

31. THANK YOU