NeoNatal JauNdice

DR.M.S.REDDY,

DNB Pediatrics,

HGH,HOWRAH,

Neonatal Jaundice• Objectives:• Define hyperbilirubinemia.• Differentiate between physiological and

pathological jaundice.• Causes of hyperbilirubinemia.• Discuss the pathophysiology of hyperbilirubinemia.• Describe the most dangerous complication of

hyperbilirubinemia.• Therapeutic management.• Design plan of care for baby has

hyperbilirubinemia.

(Hyperbilirubinemia)

• Definition: Hyperbilirubinemia refers to an excessive level of bilirubin accumulation in the blood and is characterized by yellowish discoloration of the skin, sclerae, mucous membranes and nails.

• Unconjugated bilirubin = Indirect bilirubin.

• Conjugated bilirubin = Direct bilirubin.

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Neonatal Jaundice

• Visible form of bilirubinemia

–Newborn skin >5 mg / dl• Occurs in 60% of term and 80% of preterm

neonates • However, significant jaundice occurs in 6 %

of term babies • 6-10% require phototherapy/ other

therapeutic options.

Bilirubin metabolism

Hb → globin + haem1g Hb = 34mg bilirubin

Non – heme source1 mg / kg

Bilirubin glucuronidase

Bilirubin

Bilirubin

Ligandin(Y - acceptor)

Bil glucuronide

Intestine

Bil glucuronide

Stercobilin

bacteria

β glucuronidase

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Bilirubin Production & Metabolism

Clinical assessment of jaundice(Kramer’s staging)

Area of body Bilirubin levels mg/dl (*17=umol)

Face Zone-1: 4-6Upper trunk Zone-2: 6-8Lower trunk & thighs 8-16Arms and lower legs Zone-3: 8-12Palms & soles Zone-4 :12-14 Zone-5 :>15

Causes of jaundice

Appearing within 24 hours of age• Hemolytic disease of NB : Rh, ABO• Infections: TORCH, malaria, bacterial• Red cell enzymes defects like G6PD

deficiency,pyruvate kinase

• Administration of large amount of certain drugs

like vit k, sulfonamides.

• Hereditary spherocytosis.

• Crigler-najjar syndrome,lucey-driscoll syndrome….

Causes of jaundice

Appearing between 24-72 hours of life• Physiological.• Sepsis.• Polycythemia.• Intraventricular hemorrhage.• Increased entero-hepatic circulation.• Cretinism,breastfeeding,

Causes of jaundice

After 72 hours of age• Sepsis• Cephalhaematoma• Neonatal hepatitis• Extra-hepatic biliary atresia• Breast milk jaundice• Metabolic disorders such as galactosemia,

tyrosinemia,cystic fibrosis,gilbert syndrome.

Risk factors for jaundice

JAUNDICE• J - jaundice within first 24 hrs of life• A - a sibling who was jaundiced as neonate • U - unrecognized hemolysis• N – non-optimal sucking/nursing• D - deficiency of G6PD• I - infection• C – cephalhematoma /bruising• E - East Asian/North Indian

Physiological jaundice

Characteristics:• Appears after 24-72 hours• Maximum intensity by 3th-5th day in term &

7th day in preterm• Serum level less than 15 mg / dl• Clinically not detectable after 14 days• Disappears without any treatment

Note: Baby should, however, be watched for worsening jaundice.

“Why does physiological jaundice develop?”

• Increased bilirubin load.• Defective uptake from plasma.• Defective conjugation.• Decreased excretion.• Increased entero-hepatic circulation.

“Pathological jaundice”

• Appears within 24 hours of age• Increase of bilirubin > 5 mg / dl / day• Serum bilirubin > 15 mg / dl• Jaundice persisting after 14 days• Stool clay / white colored

Causese of pathological jaundice

• Immaturity

• Hemolytic disease of the new born due to feto maternal

blood group incompatibility.• Breast milk jaundice• Hypothyroidism.• Crigler-najjar syndrome • Gilbert syndrome

• Malaria,concealed hemorrhage.

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Breast milk jaundice

• In 2-4 % EBF babies• SBr>10mg/dl beyond 3rd-4th week• Should be differentiated from Hemolytic

jaundice, hypothyroidism, G6PD def• T/t: Some babies may require PT

Continue breast feeding

Usually declines over a period of time

Dangers of hyperbilirubinemia

• Jaundice is the medical emergency.• Uncojugated bilirubin causes bilirubin

encephalopathy or kernicterus.• c/f of b.encephalopathy lethergy,hypotonia followed

by hypertonia ,refusal of feeds,shrillcry,setting sun sign,fever,convulsions,coma,retrocollis and opisthotonus .sluggish moro”s rflex.

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Kernicterus pathogenesis• Conctroversial but interplay between three points

A.unconjugated bilirubin level >20mg/dl.

B.gestational maturity of infants.

C.integrity of blood-brain barrier.

-Cross the blood-brain barrier and gains access into the neurons located in the basal ganglia,hippocampus,auditory nuclei.

-serum bilirubin/protein more than 3.5 may be associated with the brain damage.

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INVESTIGATIONS

• HISTORY OF SEVERE JAUNDICE OR EXCHANGE BLOOD TRANSFUSION OR KERNICTERUS IN A PREVIOUS SIBLING.

• MOTHER O GROUP OR RH-NEGATIVE.• ONSET OF JAUNDICE WITH IN 24 HOURS OR AFTER 72 HOURS

OF AGE.• PERSISTENT OF JAUNDIC BEYOND 3 WEEKS.• JAUNDICED INFANT WITH YELLOW-COLORED URINE OR CLAY

COLORED STOOLS.

Therapeutic Management• AIM OF THERAPY: reduce level of serum bilirubin and

prevent bilirubin toxicity• EXCHANGE BLOOD TRANSFUSION IS THE SINGLE MOST

EFFECTIVE AND RELIBLE METHOD OF TO LOWER THE BILIRUBIN WHEN IT APPROCHES CRITICAL LEVELS.

• Supportive and therapeutic measures are useful to prevent excess rise of serum bilirubin and reduce the need for EBT

“PREDICTION OF HYPERBILIRUBINEMIA IN HEALTHY NEAR-TERM AND TERM BABIES”

• Identify risk factors for development hyperbilirubinemia.

• Routine screening for serum bilirubin levels.• End-tidal corbon monoxide levels.

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PREVENTIVE AND SUPPORTIVE MEASURES

• Adequate feeding.• Aspiration of cephalhematoma.• Treatment of sepsis and hepatitis.• DRUGS:1.phenobarbitone 10mg/kg single

dose intramuscular or 5mg/kg/day in 2 divided doses orally for 3 days,2.clofibrate 50mg/kg single dose orally.

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MEASURES TO REDUCE SERUM BILIRUBIN

• PHTOTOTHERAPY:• EXCHANGE BLOOD TRANSFUSION:

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Phototheraphy• Phototheraphy is a drug.• Widely accepted and efective method.• Wave lenth is 425-475nm.• Photo-oxidation of bilirubin into water slouble

colorless forms of bilirubin like lumirubin.• AAP recommends that phototheraphy should be

started,if serum bilirubin approaches the level of 18mg/dl.(15mg/dl if baby is having hemolysis or is sick due to sepsis and perinatal distress factors).

• Phototheraphy is decline TSB@1-2mg/dl per 4-6 hours.

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Continue……• Phototheraphy may be discontnued when TSB falls below

15mg/dl.• Side effects :• Passage of loose greeen stools because of lactose intolerance

and irritant effect of photocatabolites.• Hyperthermia,irritability,and dehydration due to insensible

water loss may occur• Infants with parenchymal liver disease with biliary obstruction

may develop peculiar bronze discoloration of skin due to accumulation of one of the photoisomers designated as lumirubin.

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Precautions…….

• Phototheraphy should be avoided in direct hyperbilirubinemia and congenital porphyria.

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EXCHANGE BLOOD TRANSFUSION

• It is most effective method to reduce bilirubin levels.• Serum bilirubin level of 20-25mg/dl at the age of 4-5 days.• Early indications for exchange blood transfusion in infants

with Rh-haemolytic disease of the newborn.• A.cord Hb% <10g/dl or haematocrit <30%.• B.cord bilirubin of 5mg/dl or more.• C.unconjugated serum bilirubin of 10mg/dl with in 24 hours

or 15mg/dl within 48 hours or rate of rise of >0.5 mg/dl /hr.

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INDICATIONS FOR EXCHANGE BLOOD TRANSFUSION IN BABIES

BIRTH WEIGHT (G) TOTAL SERUM BILIRUBIN (MG/DL)

NARMAL INFANTS HIGH RISK-INFANTS

UP TO 1000 10-12 8-10

1001-1250 12-14 10-12

1251-1500 14-16 12-14

1501-2000 16-18 14-16

2001-2500 18-20 16-18

>2500 20-22 18-20

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MANAGEMENT OF IDIOPATHIC HYPERBILIRUBINEMIA IN HEALTHY TERM INFANTS

TOTAL SERUM BILIRUBIN

AGE (HOURS) CONSIDER PHOTOTHERAPHY

PHOTOTHERAPHY EBT

<24 - - -

25-48 >=12 >=15 >=20

49-72 >=15 >=18 >=25

>=72 >=17 >=20 >=25

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Babies under phototherapy

Baby under conventional phototherapy

Baby under triple unit intense phototherapy

Prognosis

• Early recognition and treatment of hyperbilirubinemia prevents severe brain damage.

PERSISTENT NEONATAL JAUNDICE

• PERSISTENCE OF JAUNDICE BEYOND 3 WEEKS MAY OCCUR DUE TO UNCONJUGATED HYPERBILIRUBINEMIA OR CHOLESTATIC JAUNDICE.

• DUE TO NON HEMOLYTIC UNCONJUGATED HYPERBILIRUBINEMIA.

• COMMONEST CAUSE IS BREAST MILK JAUNDICE.• DOWNS SYNDROME,GILBERTS

SYNDROME,HYPOTHYROIDISM,CRIGLER-NAJJAR SYNDROME,………….

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CONTINUE………………

• Conjugated hyperbilirubinemia during early neonatal period is rare.

• Occurs after 3weeks of neonatal age.• Causes of conjugated hyperbilirubinemia.• Idiopathic neonatal hepatitis.• Inspissated bile syndrome.• Infections• Malformations.• Metabolic disorders like galactocemia,tryosinemia,cystic

fibrosis…….• Chromosomal causes and miscellaneous causes……………

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Nursing considerations of Hyperbilirubinemia

• Assessment: observing for evidence of

jaundice at regular intervals. Jaundice is common in

the first week of life and

may be missed in dark skinned

babiesBlanching the tip

of the nose

Approach to jaundiced baby

• Ascertain birth weight, gestation and postnatal age• Ask when jaundice was first noticed • Assess clinical condition (well or ill)• Decide whether jaundice is physiological or

pathological• Look for evidence of kernicterus* in deeply

jaundiced NB

*Lethargy and poor feeding, poor or absent Moro's, or convulsions

The goals of planning

• Infant will receive appropriate therapy if needed to reduce serum bilirubin levels.

o Infant will experience no complications from therapy.

o Family will receive emotional support.

Thank You!