3. General objective
• At the end of this teaching learning session
students will be able to know in detail about
physiological jaundice
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4. Specific objective
At the end of the class students will be able to
• define jaundice and physiological jaundice;
• explain the physiology of physiological
jaundice;
• enlist the causes of physiological jaundice;
• enlist the risk factor associated with
physiological jaundice;
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5. Contd……….
• verbalise the sign and symptom of
physiological jaundice;
• describe the assessment and diagnosis of
physiological jaundice;
• describe the management and care of a baby
with physiological jaundice.
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6. Jaundice:
• A yellow discolouration of the skin, sclera and
mucous membrane due to an increase in the
serum bilirubin level. This becomes clinically
evident when serum bilirubin reaches about
5-7 mg/dl
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7. • The yellow discoloration of the skin is first
noted in the face and as the bilirubin level
rises proceeds caudal to the trunk and then to
the extremities.
8.
9. Physiological jaundice
• Jaundice occurring in most newborns, this
mild jaundice is due to the immaturity of the
baby's liver, which leads to a slow processing
of bilirubin.
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10. Physiological jaundice:
• Most neonates develops visible jaundice due
to elevation of unconjugated bilirubin
concentration during 1st week . This
common condition is called physiological
jaundice.
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11. Physiological Jaundice
• 50-60% Term Babies
• Occurs at day 3
• Peaks at day 5
• Lasts until approximately
day 8
• Bilirubin levels should not
exceed 200μmol/l
• 10% require phototherapy.
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12. Contd…….
The pattern of hyperbilirubinemia in
physiological jaundice has been classified
into two functionally distinct periods;
• Phase 1:
– last for 5 days in term infants and
– about 7 days in preterm infants when there is
rapid rise in serum levels to 12 to 15
mg/dl,respectively.
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13. Phase two -
• In phase two bilirubin levels decline to about
34 μmol/l (2 mg/dL) for two weeks, eventually
mimicking adult values.
– Preterm infants - phase two can last more than
one month.
– Exclusively breastfed infants - phase two can last
more than one month.
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14. Physiology of jaundice
• Blood heme+globulin
biliverdin +CO
bilirubin reductase
bilirubin
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15. Pathway of Bilirubin
• After the liver, the bilirubin enters the gall bladder and is
excreted in bile into the intestine.
• In the gut under the action of bacteria bilirubin is reduced to
urobilinogen, a small proportion is excreted in urine with the
majority excreted in faeces as stercobilinogen.
• An enzyme β glucuronidase is also present in the gut and
converts conjugated bilirubin back to unconjugated bilirubin.
There is 10times the amount of β glucuronidasae in the
neonate compared with the adult.
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17. Facts:
• 1gm Hb=35 mg of bilirubin
• Normal newborn=8.5+-2.3 mg/kg/day
• In adult:3.6 mg/kg/day
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18. Causes of Physiological Jaundice
• Short life span of fetal red blood cells
• Change from fetal cells to adult cells
• Insufficient albumin to bind to the excess
unconjugated bilirubin, leads to free unconjugated fat
soluble bilirubin.
• Sterile gut
• Poor peristalsis allows the β glucuronidase to
hydrolyse the conjugated bilirubin back to un-
conjugated bilirubin which then goes back to the liver
for further metabolism.
• Immature liver that reduces the hepatic metabolism
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19. Causes condt…
• Higher levels of red blood cells, which is more
common in small-for-gestational age (SGA)
babies and some twins
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20. Other Risk Factors For Jaundice
• Breast feeding
• Asian /Greek
• Delay in clamping the cord, increasing the volume
of blood
• Bruising – caput, cephalhaematoma
• Prematurity
• Low birth weight
• Drug
• Hypoglycemia & hypothermia
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21. Signs and Symptoms of Jaundice
• Discoloration of the
skin, sclera
• Lethargy
• Poor feeding
• Yellow urine and stool
• Irritability
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22. Complications of Jaundice
High levels of bilirubin — usually above 25 mg
— can cause deafness, cerebral palsy, or other
forms of brain damage in some babies.
Risk that the fat soluble bilirubin crosses to
the brain to cause Bilirubin Encephalopathy
known as Kernicterus.
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23. Assessment of Physiological Jaundice
• Clinical observation. Jaundice visible at 5-7
mg/dl.
• Jaundice is caudal in direction, i.e. from head
down the body.
• Kramer’s rule
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26. Investigation
• Clinical history of mother/family.
• History of bruising / cephalohematoma / birth
trauma.
• Blood grouping and rhesus factor.
• Feeding pattern.
• Infection.
• Drugs.
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27. Management
• No action for the vast majority of babies with
physiological jaundice
• Measure the Serum Bilirubin
• The level of serum bilirubin actually indicates
what treatment is required:
– To continue to observe but no additional
intervention
– Repeat test
– Phototherapy
– Exchange blood transfusion (unlikely for
physiological jaundice)
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29. Phototherapy
• First discovered, accidentally, at Rochford Hospital
in Essex, England
• Ward sister of the premature baby unit firmly
believed that the infants under her care benefited
from fresh air and sunlight in the courtyard
• When serum bilirubin was checked indicated a
much lower level of bilirubin tha earlier
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30. • Dr. Cremer's published the facts in
the Lancet in 1958
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31. Mode of action
• Isomerization that changes trans-bilirubin into
the water-soluble cis-bilirubin isomer.
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32. • Blue-green light in the range of 460-490 nm is
most effective for phototherapy.
• The absorption of light by the normal bilirubin
(4Z,15Z-bilirubin) generates configuration
isomers, structural isomers, and
photooxidation products.
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33. Factors affecting dose of phototherapy
• Irradiance of light used,
• The distance from the light source, and
• The amount of skin exposed.
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34. • Standard phototherapy is provided at an
irradiance of 8-10 microwatts per square
centimeter per nanometer (mW/cm2 per nm).
• Intensive phototherapy is provided at an
irradiance of 30 mW/cm2 per nm or more
(430–490 nm).
35. • For intensive phototherapy, an auxiliary light
source should be placed under the infant.
• The auxiliary light source could include a fiber-
optic pad, a light-emitting diode (LED) mattress,
or a bank of special blue fluorescent tubes.
• Term and near-term infants should receive
phototherapy in a bassinet and the light source
should be brought as close as possible to the
infant, typically within 10-15 cm.
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36. Guidelines for management of
hyperbilirubinemia in healthy, full-term
infants (American Academy of Pediatrics)
• Age 25-48 hours**:
>12 -Consider phototherapy
>15 -Initiate phototherapy
>20 -Initiate exchange transfusion if intense
phototherapy* fails
>25 -Initiate exchange transfusion
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37. • Age 49-72 hours
>15 -Consider phototherapy
>18 -Initiate phototherapy
>25 -Initiate exchange transfusion if intense
phototherapy* fails
>30 -Initiate exchange transfusion
Age >72 hours
>17 -Consider phototherapy
>20 -Initiate phototherapy
>25 -Initiate exchange transfusion if intense
phototherapy* fails
>30 -Initiate exchange transfusion
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38. An example of an action chart for bilirubin
results
www.ich.ucl.ac.uk/clinical_information/clinical_guidelines/downloads/phototherapy.pdf
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41. Care of baby
• Early feeding/ Nutrition/ Hydration
• Increase frequency of breast feeding
• Neutral thermal environment
• Prevent hypoglycaemia and hypoxia
• Avoid constipation
• Hygiene
•
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44. Reference
• Ghai . OP.Essential Paediatric. 6th edition CBS
publication and distributors page no:169-171
• Dutta D.C. Text book of obstretics. 7th
edition.New book agency(p)ltd page no:476
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45. Contd……..
• College of Family Physicians of Canada (1999)
Approach to the
management of hyperbilirubinemia in term
newborn infants paeditrics & Child Health 4(2);
161-164
http://www.cps.ca/english/statements/FN/fn98-
02.html (retrived on 11 dec 2o11)
•
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47. Multiple choice questions
1.physiological jaundice starts to appear on:
A. At the time of birth;
B. 2-3 day of life;
C. 7 days of life;
D. 15 days of life
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48. 2.End product of R.B.C destruction which causes
yellowish discoloration of body is:
A. Globulin
B. Albumin
C. Biliverdin
D. Bilirubin
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49. 3. Conjugation of bilirubin takes place in:
A. Intestine
B. Lung
C. Liver
D. kidney
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50. 4. All of the following are the causes of
physiological jaundice, except:
A. Sterile gut
B. Short life span of R.B.C
C. Constipation
D. Mature liver
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51. 5. Jaundice first appears in
A. Foot
B. Hands
C. Sclera of eyes
D. abdomen
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52. Assignment
• While you are posted in pediatric ward:1 a 5
days old baby is having serum total bilirubin
level 10 mg/dl , and not sucking breast milk .
Make a nursing care plan for the baby.
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