This document presents a case study of neonatal jaundice in a 3-day old male infant. The infant presented with yellowish skin discoloration up to the soles and poor feeding for 1 day. Examination found physiological jaundice that progressed from the face to the soles over 3-4 days, peaking on days 4-6 before resolving by day 12. The diagnosis was physiological jaundice given the timing of onset and resolution without signs of pathology. The infant was treated conservatively with supportive care and monitoring.

1. CASE PRESENTATION
ON
NEONATALJAUNDICE
Presented by:
Dr.Rashi Jaiswal
M.D.1st Year
P.G Deptt. Of Bal roga

2. NEONATAL JAUNDICE

4. Jaundice
It is a yellowish staining of body tissues and fluids, as a result of
excessive level of bilirubin in the blood stream.
Neonatal Jaundice
When Jaundice observed during the 1st wk of life called Neonatal
Jaundice . It is a cause of concern for the physician and a source of
anxiety for the parents . High bilirubin levels may be toxic to the
developing CNS and may cause neurological impairment even in
term newborns.
Incidence of N. Jaundice
60% of Term infants 80% of Preterm infants
Clinically detected in New born when serum bilirubin level is >
5mg/dl.

5. Neonatal jaundice
Pathological
jaundice
Breast milk jaundice
Physiological
jaundice
• Within 24 hrs after
birth
• After 10-15 days after
birth
• Hyperbilirubinemia
• STB levels exceeds
5mg/dl on 1st day,
10mg/dl on 2nd day,
12-13mg/dl
thereafter in term
babies
• It represents physiological
immaturity of the neonates to
handle increased bilirubin
production.
• It rises at the rate of <5mg/dl
in 24 hr.
• Jaundice become visible on 2nd
-3rd day
• Peak level between 3rd -4th day
• Decrease on 5th – 7th day
• Approx 2-4% of exclusively
breast fed term babies
have jaundice >10mg/dl
• Found beyond 3rd -4th week
of life
• Diagnosis is made when it
is unconjugated and other
causes such as
hemolysis,G6PD
deficiency,hypothyroidism
have been ruled out.
• It needs no intervention.

7. BILIRUBIN METABOLISM

8. CAUSE OF JAUNDICE
(on the basis of age of onset )
APPEARING WITH IN
HRS
APPEARING BETWEEN
24-72 HRS
APPEARING AFTER 72
HRS
• Hemolytic disease of
new born ,Rh , ABO &
minor blood group
incompatibility.
• Infection- intrauterine
viral or bacterial.
• G6PD Deficiency.
• Congenital malaria.
• Physiological.
• G6PD Deficiency.
• Sepsis
• Polycythemia.
• Concealed
haemorrhage.
• Increased entero
hepatic circulation
• Sepsis
• Neonatal hepatitis
• Extra hepatic billiary
atresia
• Breast milk jaundice
• Metabolic disorders

9. Physiological Mechanisms of Neonatal
Jaundice
1. Increased bilirubin production
Higher erythrocyte mass
Shorter RBC lifespan(90 days)
Increased ineffective erythropoiesis
Increased turnover of non haemoglobin heme protein
2. Reduced hepatic metabolism
 New borns have immature liver function, leading to slower
metabolism of bilirubin.
3. Increased Enterohepatic circulation
Paucity of intestinal bacteria
Decreased gut motility
Delay in passage of meconium causes increased reabsorption of
bilirubin in intestines.

10. INVESTIGATIONS
The aim of performing investigations is to confirm the level of jaundice the level ,
identify the cause and follow response to treatment.
FIRST LINE
 Total serum bilirubin :All cases with suspected pathological levels either clinically or
by transcutaneous measurements need confirmation by blood examination of serum
bilirubin levels.
Blood groups of mother and baby (if the mother is O or Rh negative):detects any
incompatibility.
Peripheral smear : evidence of hemolysis
SECOND LINE
Direct Coombs test: detects presence of antibody coating on fetal RBC
Hematocrit: decreased in hemolysis
Reticulocyte count : increased in hemolysis
G6PD levels in RBC

11. Clinical Methods of detection of Neonatal-Jaundice
By Kramer’s Method
Originally described by Kramer, dermal staining of bilirubin may
be used as a clinical guide to the level jaundice. Dermal staining
in new-borns progress in a cephalo-caudal direction .The new
born is to be examined in a good day light . The skin of forehead ,
chest , abdomen , thighs , legs , palms and soles should be
blanched with digital pressure and underlying color of skin and
subcutaneous tissue is noticed.
Icterometer:-
5 Strips-pressed against tip of nose , colour of skin is matched
with strip
Transcutaneous bilirubinometer:-
Photoprob is pressed against skin of forehead or sternum.
Digitaldisplay of bilirubin level is made immediately.

12.  Zone 1- Above clavicle i.e face -4-6 mg/dl
Zone II-Chest, upper abdomen-6-8 mg/dl
Zone-III-Thighs, lower Ab,upper arm.-8-12
mg/dl
Zone-IV-Lower legs, forearm-12-14 mg/dl
Zone-V-feet, Hands (Palms & Soles)->15
mg /dl
Clinical Quantification

13. Physiological Jaundice
The parents should be explained about the benign nature of jaundice .The
mother should be encouraged to breastfeed frequently and exclusively.
Mother should be told to bring the baby to the hospital if baby looks deep
yellow or palms and soles have yellow staining .There is no use to expose
the baby to direct sunlight to reduce hyperbilirubinemia.
Any newborn discharged prior to 72 hr of life should be evaluated again in
the next 48hr for assessment of adequacy of breastfeeding and progression
of jaundice.
Pathological jaundice
The underlying cause of pathological jaundice must be treated.
If bilirubin levels necessitate it, treatment for jaundice involves phototherapy
and /or exchange transfusion of donor blood.
MANAGEMENT

14. PHOTOTHERAPY
The most commonly used treatment is fluorescent light exposure, in
which the infant is placed under a lamp for a few hours each day.
The blue light breaks down bilirubin into a form that infant liver can
process and eliminate. In this unconjugated bilirubin gets converted
into water-soluble photo products on exposure to light of a
particular wavelength i.e 425-475nm. These photoproducts are
water soluble and non toxic and excreted in intestine and urine.
For phototherapy- there should be visible bilirubin in the skin.

16. Indication:-
Birth wt. Serum bilirubin
 2500 gm 15 mg/dl
2000-2500gm 12mg/dl
1500-2000gm 10mg/dl
1000-1500gm 7mg/dl
<1000gm 5mg/dl
Bilirubin absorbs light maximum at 450-476 nm.

17. EXCHANGE TRANSFUSION
When neonatal jaundice is more severe, and fluorescent light
therapy is unable to break down all circulating bilirubin,
exchange transfusion is often used.
High levels of bilirubin in the blood can lead to brain damage
and other serious problems. In these cases, exchange transfusion
is a life-saving procedure designed to counteract the effects of
serious jaundice, infection, or toxicity.
The procedure involves the staged removal of the infant's blood
and replacement with fresh donor blood or plasma

18. PHARMACOLOGICAL TREATMENT
1 Phenobarbitone:-Several studies have shown that
phenobarbital is effective in reducing mean serum bilirubin
values in first week of life. It induces the hepatic bilirubin
metabolism. It can be administered prenatally in the mother or
postnatally in the infant . But it has its own side effects , so this
treatment is probably not justified in populations with a low
incidence of severe neonatal jaundice.
2 Metalloporphyrins:- In selected neonates full term with
severe hyperbilirubinaemia, a single dose of mesoporphyrin &
Tinporphyrin is given. But there is no evidence to support or
refute its effect and is not much used in practice.
3 High dose I.V immunoglobulin:-
◦ In hemolytic Jaundice such as Rh or ABO incompatibility
◦ Dose-500-1000 mg/kg as slow infusion for 2 hrs.

19. PREVENTION
Antenatal investigations should include maternal blood
grouping.Rh positive baby born to a Rh negative mother is at a
higher risk and requires greater monitoring.
Anti-D injection after first obstetrical event ensures decreased
risk of sensitization in future pregnancies.
Ensuring adequate breast feeding.
Parent education regarding danger signs should include
yellowish discoloration below knees and elbows and persistent
jaundice beyond 15 days as reason for immediate checkup by
health personnel.
High risk babies such as with large cephalohematoma or family
history of jaundice should be asked to come for follow-up after 3
days of discharge and reassessed.

21. • Name :B/O Lobha kumari
• Age : 3days
• Sex :male
• Father’s Name : Sh.Ravinder Kumar
• Informant :Mother
• Address :V.P.O. -Bhattu ,
Teh. Baijnath, Distt.- Kangra
• IPD No. :597
• Date of Admission :15/12/19
• Date of examination :17/12/19

22. Chief complaint :-
Yellowish discolouration of skin since 2 days
Refused to feed since 1 day
History of Present illness:-
According to the mother , baby was quite
asymptomatic 2 days back . Then in evening she
observed the yellowish discoloration of the skin which
was present up to sole. She also revealed that her baby
was not taking feeds properly and sucking at breast
was poor since morning.With these complaints, she
reported in balaroga deptt.

23. Birth history :-
•NVD with RMLE on 15/12/2019 at 8:22PM.
•Baby cried immediately after birth.
•Active suction of mouth and nose was done properly.
•Baby was kept under radiant heat warmer for half an hour
under observation.
•No congenital abnormality was seen externally.
 APGAR at 1 min.- 8
at 5 min.- 10

24.  Vitals at birth:
HR- 136/min
RR- 52/min.
Reflexes :-
(i) Moro reflex : present WNL
(ii)Rooting reflex : present WNL
(iii)Sucking Reflex : present WNL
(iv)Grasp Reflex : present WNL
 U. cord – Normal anatomy
 B.Wt. - 3.7Kg
 Chest - B/L clear airways
 Abdomen – Soft and non tender

25. Maternal history:-
•LMP- 5/03/19
•EDD- 12/12/19
•O/H- primigravida
•B.group- B+ve
•Hb.- 11gm%
•HIV-NR
•VDRL-NR
•HBsAg-NR
Antenatal History:- No H/O Infection,
Irradiation & any teratogenic &
toxic drug intake.
•Four ANC done at RAH Paprola.

26. Family History:-
Father : Healthy
Mother : Healthy
Socio-economic history :-
House : Pucca, well ventilated
Surroundings : Clean
Source of water : Tap water
Ventilations : Proper
Status : Upper middle class

27. General Physical Examination :-
• Generalappearance :active
• Skin :yellowishdiscoloration
presentuptosole(onblanchingtipof
soul)
• Head
Ant.Fontanelle :Flat,notdepressedorraised
Hair :Normalcoarse,silkyand
brownishblackincolor.
• Eyes :Yellowish(bulbarconjunctiva)
• Nose :Normal,NoDNS
• Ears :Normal
• Neck :Normal,nowebbedneck
• Breast : Normal,withequallyspacednipples

28. Upper limb: NAD
Lower limb: NAD
Ext. Genitalia : Normal
Anthropometry
Head circumference : 34 c.m.
Crown heel length : 48 c.m.
Chest circumference : 32 c.m.
Mid arm circumference : 13 c.m.

29. On observation:
Child was kept under observation since birth.After 48 hrs of
birth yellowish discoloration was present up to face
(according to mother) on observation which gradually
progresses to chest and then abdomen .On 3rd and 4th day
mild icterus was present up to soles.Which gradually
regresses to legs ,thighs , Abdomen, chest and on 9th day
there was mild icterus on face. On further observation
icterus disappeared.
Provisional diagnosis:- Newborn with physiological
jaundice.

30. Differential Diagnosis :-
• Pathological jaundice (Jaundice appears with in 24 hrs.
• Presence of clinical jaundice beyond 2 Wk.
• Conjugated bilirubin (Staining the nappy dark) in the
urine.
• Breast milk jaundice
Positive findings:-
• Jaundice appeared after 24hrs
• Maximum intensity on 4th and 6th day.
• Clinically disappears on 12th day
Final Diagnosis: Newborn with Physiological
jaundice

31. Treatment Given :-
• Keep the baby warm with mother for 24 hr.
• Exclusive breast feeding for 6 months.
• Burping is to be done after each feed.
• Care of eyes and umbilical cord to be done.
• Adliv drops 3 drops TID.
Self limiting needs no treatment. Baby should however
needs to be watched for further worsening symptoms.

32. Thank You