Jaundice in newborns

1. Neonatal jaundice
 Almost all newborn infants develop a total serum or
plasma bilirubin (TB) level greater than 1 mg/dl.
 Hyperbilirubinemia refers to an excessive level of
accumulated bilirubin in the blood and is characterized
by a yellowish discoloration of the skin, sclerae, mucous
membranes and nails which is called jaundice.
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2.  Severe neonatal hyperbilirubinemia is defined as a TB
>25 mg/dL
Incidence
Term—60%
Preterm—80%
Bilirubin Source
Hb – 80%
Non Hb – 20% (Myoglobin
- catalase
-cythochromes 2

3. Classification of neonatal jaundice
1.Physiologic Jaundice
 Seen both in term and preterms
 Self limiting
 Develops after 24 hours
 Peaks by day 4- 5 in terms and day 7-8 in preterms
 Peak levels -12mg/dl in term & 15mg/dl in preterm
 Gradually subsides by 10-14 days
 No Treatment necessary 3

4. Causes of physiologic jaundice
 Accelerated destruction of fetal RBCs
- Increased amounts of bilirubin delivered to liver
- Inadequate hepatic circulation
 Impaired conjugation of bilirubin
- Defective uptake of bilirubin from the plasma
- Defective conjugation of the bilirubin
 Increased bilirubin reabsorption
- Defect in bilirubin excretion
- Increased reabsorption of bilirubin from the intestine 4

5. Breastfeeding Jaundice
- Bilirubin levels begin to rise about the fourth day after mature
breast milk comes in
- Peak of 5-10mg/dl is reached at 2 to 3 weeks of age
- Composition of breast milk may interfere with conjugation
- It may be necessary to interrupt breastfeeding for a short period
when bilirubin reaches 20mg/dl
- Continue to pump
- Reassure the mother
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6. Breastfeeding failure 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
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7. Pathologic jaundice
 It appears in the 1st 24hr of life,
 Serum bilirubin is rising at a rate faster than 5mg/dL/24hr
 Serum bilirubin is greater than 12mg/dL in full-term, 14mg/dL in
preterm infants
 Jaundice persists after 10–14 days of life
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8. Management of neonatal jaundice
 Regardless of the cause, the goal of therapy is to prevent the
concentration of indirect-reacting bilirubin in the blood from
reaching levels at which neurotoxicity may occur
 It includes:
 Phototherapy
 Exchange transfusion
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9. 1. Phototherapy
 Conversion of insoluble Bilirubin into soluble b.
 Safe and effective method for treatment of neonatal
jaundice

10. Indication of phototherapy
 TSB > 15 mg in term
 TSB > 12 mg in preterm
 TSB > 5 mg within 24 hours
 Adjuvant to exchange transfusion
 Prophylactic PT
ELBW,
bruised babies,
hemolytic disease of NB,
VLBW with Perinatal risk factors

11.  Precautions
 Cover the eyes and Genitals
 Supplemental hydration
 Watch for side effects
 Best is narrow spectral blue lights (425-475nm)
 Distance from skin – 45cm

12. Side effects of phototherapy
 Hyperthermia, increased fluid loss and dehydration
 Damage to retina from high intensity light
 Decreased eagerness to feed
 Skin rashes
 Lack of visual sensory experiences
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13. Exchange Transfusion
 Mechanism: removes bilirubin and antibodies from circulation
and correct anemia
 Most beneficial to infants with hemolysis
 Generally never used until after intensive
phototherapy attempted

14. Kernicterus
 Kernicterus is damage to the brain centers of infants
caused by increased levels of unconjugated-indirect
bilirubin which is free (not bound to albumin).
 Affects basal ganglia, cranial nerve nuclei, brain stem
nuclei, hippocampus and AHC of spinal cord (cortex
usually spared)
 Necrosis,
 neuronal loss and
 gliosis

15. Chronic complications
 Choreo-Athetosis
 Partial or complete sensorineural hearing loss
 Limitation of upward gaze
 Dental dysplasia
 Intellectual deficits

16. Prematurity
 Prematurity is defined as a birth that occurs before 37 completed
weeks of gestation.
 Infants born at or before 25 weeks gestation have the highest
mortality rate (about 50 percent) and if they survive, are at the
greatest risk for severe impairment.
 Different degrees of prematurity are defined by gestational age, or
birth weight.
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17.  One classification based upon Birth weight includes the following
categories :
 Low birth weight (LBW) – BW less than 2500 g
 Very low birth weight (VLBW) – BW less than 1500 g
 Extremely low birth weight (ELBW) – BW less than 1000 g
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18. Prematurity…
 Prematurity is also defined by GA as follows:
 Late preterm infants – GA between 34 weeks and 36 weeks and 6 days
 Very preterm (VPT) infants – GA at or below 32 weeks
 Extremely preterm (EPT) infants – GA at or below 28 week
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19. Characteristics of premature baby
 Compared with the term infant, the premature infant is:
 Tiny, scrawny, and red.
 The extremities are thin with very little muscle or s/c fat
 Head and abdomen are disproportionately large and the
skin thin, relatively translucent

20. Prematurity…
 Usually wrinkled vein of the abdomen and scalp are more visible
 The ears have soft, minimal cartilage, and thus are very pliable
 The soft bones of the skull have a tendency to flatten on the
sides, and the ribs yield with each laboured breath.

21. Prematurity…
 Testes are undescended in the male; labia and clitoris are quite
prominent in the female.
 The soles of the feet and palms of the hands have few creases
 Many of the typical newborn reflexes are weak or absent.

22. Prematurity…
 In the prone position the premature infant lies with pelvic flat and
leg spread in a frog like position.
 While term infant lies with limb flexed, pelvis raised, and knees
drawn up under abdomen
 The premature infant has altered physiology due to immature and
often poorly developed system

23. Prematurity…
 Respiratory muscles are poorly developed, chest wall lack
stability, production of surfactant is reduced, and breathing
may be laboured and irregular with period of apnoea and
cyanosis.
 Infant prone to atelctasis
 Gag and cough reflexes are poor, thus aspirations are problem
 Stomach is small vomiting is likely to occur

24. Prematurity…
 Have very little subcutaneous fat thus there is no heat storage
or insulation, cannot shiver, has poor vasomotor control of
blood flow to the skin capillaries
 There is relatively high surface area in comparison with body
weight

25. Prematurity…
 Has reduced muscle and fat deposited that restrict metabolic
rate and heat production
 Response to stimuli is low : suck, swallow, gag, and cough
reflexes are poor : feeding and aspirations are also problem

26. Prematurity…
 Actively formed antibodies and IgM are absent at birth
 Liver does not have ability to handle and conjugate
bilirubin, do not release and store glucose well

27. Causes of prematurity birth
Fetal - Fetal distress
 Multiple gestations
 Erythroblastosis

28. Factors involving the pregnancy
 Abnormal or decreased function of the placenta.
 Placenta previa (low lying position of the placenta).
 Placental abruption (early detachment from the uterus).
 Premature rupture of membranes (amniotic sac).
 Polyhydramnios (too much amniotic fluid).

29.  Maternal - Preeclampsia
 Chronic medical illness
 Infections
 Drug abuse
 Cervical incompetence
 Maternal age and parity
 Premature rupture of membranes
 Polyhydramnious

30. Main problems of prematured newborns
 hyaline membrane disease
 apnea
 hypoglycemia
 hypocalcemia
 hyperbilirubinemia
 anemia
 bacterial sepsis

31.  Temperature instability (inability to stay warm due to low body
fat).
 Respiratory problems as hyaline membrane disease (condition in
which the air sacs cannot stay open due to lack of surfactant in
the lungs).
 Apnea which occurs in about half of babies born at or before 30
weeks.

32. Care of premature neonates
Thermal management
 The premature newborn encounters the problem of severe
heat loss for several reasons.
 large body surface area relative to body mass

33.  the tiny baby's small size presents a much smaller heat sink
to store thermal reserve
 minimal shivering during exposure to cold