الرحيم الرحمن الله الرحيم بسم الرحمن الله بسم

Jaundice in the newbornJaundice in the newborn

DR Husain AlsaggafDR Husain Alsaggaf

Jaundice in the newbornJaundice in the newborn

ClinicalClinical jaundice jaundice appear at SB 5 mg/dlappear at SB 5 mg/dl

25% to 50% of term 25% to 50% of term newborns have clinical newborns have clinical jaundice.jaundice.

Jaundice may caused Jaundice may caused by serious illness or by serious illness or lead to keriniectrus.lead to keriniectrus.

75% of bilirubin comes 75% of bilirubin comes from haemoglobin and from haemoglobin and 25% from other sources25% from other sources

Neonatal jaundiceNeonatal jaundice

Neonatal jaundice

physiological pathological

unconjugatedconjugated

Intrahepatic

Hepatic injures

Extrahepaitc

infectious

metabolic

Neonatal hepatitis

Paucity of hepatic ducts

Physiological jaundicePhysiological jaundice

Start after the first 24hours.Start after the first 24hours.Peak in the fourth or fifth day {not >12 Peak in the fourth or fifth day {not >12

mg/dl} in term babies and not more than mg/dl} in term babies and not more than 15 mg/dl in premature15 mg/dl in premature

The baby is well.The baby is well.Clear in week in term and two weeks in Clear in week in term and two weeks in

premature.premature.Bilirubin is unconjucated.Bilirubin is unconjucated.The rise is not more than 0.5 mg /hThe rise is not more than 0.5 mg /h

Causes of physiological jaundiceCauses of physiological jaundice

High haemoglobinHigh haemoglobin Decrease RBC life Decrease RBC life

span.span. Increase Increase

enterohepatic enterohepatic circulation.circulation.

Defective conjugation.Defective conjugation. Decrease hepatic Decrease hepatic

excretionexcretion

Pathological jaundicePathological jaundice

UnconjucatedUnconjucated High Hg massHigh Hg mass Haemolysis.Haemolysis.

Blood group Blood group incompqatability.(RH.ABO.)incompqatability.(RH.ABO.)

Red cell membrane defect Red cell membrane defect (spherocytosis)(spherocytosis)

Heamoglobinopathy.Heamoglobinopathy. Haemolytic agents (vit Haemolytic agents (vit

k3.oxytocin)k3.oxytocin) Infection E.coli septicaemiaInfection E.coli septicaemia

Causes of unconjucated Causes of unconjucated hyperbiliruniemiahyperbiliruniemia

Liver cell membrane defect (GILBRET).Liver cell membrane defect (GILBRET).Defective conjugation.Defective conjugation.

Jaundice of prematurity.Jaundice of prematurity.Breast milk jaundice.Breast milk jaundice.Hypothyroidism.Hypothyroidism.Hereditary(crigler-najjar).Hereditary(crigler-najjar).Other conditions Pyloric stenosis,infant of Other conditions Pyloric stenosis,infant of

diabetic mother, down's syndromediabetic mother, down's syndrome

Investigation of unconj-Investigation of unconj-hyberbilirubinneamiahyberbilirubinneamia

Split biliurubin.Split biliurubin.Blood groups and Rh.Blood groups and Rh.coomb’s test.coomb’s test.CBC and reticulocyte.CBC and reticulocyte.G-6-P-D estimationG-6-P-D estimation

Blood film and osmotic fragility test.Blood film and osmotic fragility test.

TFT and urine for reducing substance.TFT and urine for reducing substance.

Causes of conjugated Causes of conjugated hyberbilirubineamiahyberbilirubineamia

Hepatitis: CMV.toxoplasmosis.rubella.herpes.giant Hepatitis: CMV.toxoplasmosis.rubella.herpes.giant cell,Hep A and b,syphilis,E coli.cell,Hep A and b,syphilis,E coli.

Metabolic: Metabolic: Galctosemia,Tyroseanemia,Fructoseamia.Galctosemia,Tyroseanemia,Fructoseamia.

Cystic fibrosis.Cystic fibrosis. Alpha one anti trypsin deficiency.Alpha one anti trypsin deficiency. Gauchers and neimman pickGauchers and neimman pick Biliary Artesia (intrahepatic and extrahepatic)Biliary Artesia (intrahepatic and extrahepatic) Choldoccal cyst.Choldoccal cyst. T.P.NT.P.N

Investigation of conjugated Investigation of conjugated hyperbiliruniemiahyperbiliruniemia

L.F.TL.F.T PT.PTT.PT.PTT. Urine for glucose and Urine for glucose and

reducing substance.reducing substance. Serum and urine amino Serum and urine amino

acid determinations.acid determinations. TORCH serology.TORCH serology. Ultrasound.Ultrasound. Liver scanLiver scan Duodenal aspiration.Duodenal aspiration. Liver biopsy.Liver biopsy.

Approach To neonatal jaundiceApproach To neonatal jaundice

History.History. FH of aneamia,spleenomegaly.FH of aneamia,spleenomegaly. Jaundice in other sibling (breast Jaundice in other sibling (breast

milk jaundice.Rh disease)milk jaundice.Rh disease) FH of liver disease FH of liver disease

(galactoseamia,alpha-one- (galactoseamia,alpha-one- antitrypsin difficiency,cystic antitrypsin difficiency,cystic fibrosis, Gilbert and crigler-najjar)fibrosis, Gilbert and crigler-najjar)

Maternal illness during Maternal illness during pregnancy (TORCH and pregnancy (TORCH and diabetes).diabetes).

Maternal drugs.(sulfanomideMaternal drugs.(sulfanomide Labour and Labour and

delivery(Truma,oxytocin,delayed delivery(Truma,oxytocin,delayed clamping of the cord,prematurity.clamping of the cord,prematurity.

Infant history.Infant history. Feeding (breast milk Feeding (breast milk

jaundice).jaundice). Poor feeding.Poor feeding. Vomting(sepsis Vomting(sepsis

pyloric pyloric stenosis,galactosemiastenosis,galactosemia

ExaminationExamination

Small for date(polycythemia, in-utroinfection.Small for date(polycythemia, in-utroinfection. PrematurePremature Extravagated blood(briuses ,cephaloheamatoma).Extravagated blood(briuses ,cephaloheamatoma). Pallor(heamolytic anaemia and extravagated blood)Pallor(heamolytic anaemia and extravagated blood) Cherioretinitis,cataract,(congenital Cherioretinitis,cataract,(congenital

infection,galactoseamia)infection,galactoseamia) Petechia rash (congenital infection,galactoseamia)Petechia rash (congenital infection,galactoseamia) Hepatospleenomegaly(heamolytic Hepatospleenomegaly(heamolytic

anaemia ,congenital infection, liver diseases)anaemia ,congenital infection, liver diseases)

ManagementManagement

Prevention:Prevention:Rh incompatibility----- Anti D Rh incompatibility----- Anti D Syphlis---PencillineSyphlis---Pencilline

Specific therapy:Specific therapy:Septicaemia---- Antibiotic.Septicaemia---- Antibiotic.Surgery------------ Ex hepatic biliary Artesia.Surgery------------ Ex hepatic biliary Artesia.Galctose withdrawal for galactoseamia.Galctose withdrawal for galactoseamia.

Management of unconjucated Management of unconjucated hyberbilirubineamiahyberbilirubineamia

PhototherapyPhototherapy

Wave length 450-460 --Wave length 450-460 -- Reduce bilirubin To Reduce bilirubin To harmless compound harmless compound excreted in the urine.excreted in the urine.

Complication:Complication: Retinal damage, nasal Retinal damage, nasal

obstruction, mild obstruction, mild diarrhea,dehydration,brodiarrhea,dehydration,bronzed baby syndromenzed baby syndrome

Exchange TransfusionExchange Transfusion

Indicated when bilirubin Indicated when bilirubin reach toxic level.reach toxic level.

Mortality1%Mortality1% Remove Remove

bilirubin ,antibodies ,correct bilirubin ,antibodies ,correct anaemia.anaemia.

Double blood volume is Double blood volume is used 85 ml /kgused 85 ml /kg

COMPLICATION.COMPLICATION. Infection,acidosis,Cadiac Infection,acidosis,Cadiac

failure, Electrolytes failure, Electrolytes imbalance.imbalance.

PhenobarbitonePhenobarbitone

This act as enzyme inducer which This act as enzyme inducer which increase amount of glucoreny transferase increase amount of glucoreny transferase and protein z.and protein z.

Used in crigler najjarUsed in crigler najjar

KernicterusKernicterus

Yellow staining of nuclear Yellow staining of nuclear centres of the braincentres of the brain

Due to high level of indirect Due to high level of indirect bilirubin.bilirubin.

Bilirubin cause neural loss.Bilirubin cause neural loss. Bilrubin inhibit cell Bilrubin inhibit cell

respiration, protein respiration, protein synthesis,glucouse synthesis,glucouse metabolism.metabolism.

Poor feeding and lethargy-Poor feeding and lethargy- fits,rigidity fits,rigidityspacsticty spacsticty deafnes,athetosisdeafnes,athetosis