Neonatal jaundice

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

pathological jaundice.pathological jaundice.• State causes of hyperbilirubinemia.State causes of hyperbilirubinemia.• Discuss the pathophysiology of Discuss the pathophysiology of

hyperbilirubinemia.hyperbilirubinemia.• Describe the most dangerous complication Describe the most dangerous complication

of hyperbilirubinemia.of hyperbilirubinemia.• List the three elements of therapeutic List the three elements of therapeutic

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

hyperbilirubinemia.hyperbilirubinemia.

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Neonatal Jaundice(Hyperbilirubinemia)

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

• UnUnconjugated bilirubin = conjugated bilirubin = InIndirect bilirubin.direct bilirubin.• Conjugated bilirubin = Direct bilirubin.Conjugated bilirubin = Direct bilirubin.

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Neonatal Jaundice• Visible form of bilirubinemia Visible form of bilirubinemia

–Newborn skin >5 mg / dlNewborn skin >5 mg / dlOccurs in 60% of term and 80% of Occurs in 60% of term and 80% of

preterm neonatespreterm neonatesHowever, significant jaundice occurs in However, significant jaundice occurs in

6 % of term babies 6 % of term babies

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Bilirubin Production & Metabolism

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Clinical assessment of jaundice

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

Face Face 4-8 4-8Upper trunkUpper trunk 5-12 5-12Lower trunk & thighsLower trunk & thighs 8-16 8-16Arms and lower legsArms and lower legs 11-18 11-18Palms & solesPalms & soles > 15 > 15

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Physiological jaundice

CharacteristicsCharacteristics• Appears after 24 hoursAppears after 24 hours• Maximum intensity by 4th-5th day in term Maximum intensity by 4th-5th day in term

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

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

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Why does physiological jaundice develop?

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

circulation.circulation.

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Age in Days

TermPreterm

1 2 3 4 5 6 10 11 12 13 14

15

10

5Bil

iru

bin

leve

lm

g/d

l

Course of physiological jaundice

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Pathological jaundice

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

staining clothes yellowstaining clothes yellow• Direct bilirubin> 2 mg / dlDirect bilirubin> 2 mg / dl

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Causes of jaundice

Appearing within 24 hours of age• Hemolytic disease of NB : Rh, ABOHemolytic disease of NB : Rh, ABO• Infections: TORCH, malaria, Infections: TORCH, malaria,

bacterialbacterial• G6PD deficiencyG6PD deficiency

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Causes of jaundice

Appearing between 24-72 hours of

life• PhysiologicalPhysiological• SepsisSepsis• PolycythemiaPolycythemia• Intraventricular hemorrhageIntraventricular hemorrhage• Increased entero-hepatic circulationIncreased entero-hepatic circulation

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Causes of jaundice

After 72 hours of ageAfter 72 hours of age• SepsisSepsis• CephalhaematomaCephalhaematoma• Neonatal hepatitisNeonatal hepatitis• Extra-hepatic biliary atresiaExtra-hepatic biliary atresia• Breast milk jaundiceBreast milk jaundice• Metabolic disorders (G6PD).Metabolic disorders (G6PD).

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Risk factors for jaundice

JAUNDICEJAUNDICE• JJ - jaundice within first 24 hrs of life - jaundice within first 24 hrs of life• A A - a sibling who was jaundiced as neonate - a sibling who was jaundiced as neonate

• U U - unrecognized hemolysis- unrecognized hemolysis• N N – non-optimal sucking/nursing– non-optimal sucking/nursing• DD - deficiency of G6PD - deficiency of G6PD• I I - infection- infection• CC – cephalhematoma /bruising – cephalhematoma /bruising• E E - East Asian/North Indian- East Asian/North Indian

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Diagnostic evaluation:

• Normal values of unconjugated B. are Normal values of unconjugated B. are 0.2 to 1.4 mg/dL.0.2 to 1.4 mg/dL.

• Investigate the cause of jaundice.Investigate the cause of jaundice.

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Therapeutic Management

• PurposesPurposes: reduce level of serum bilirubin : reduce level of serum bilirubin and prevent bilirubin toxicityand prevent bilirubin toxicity

• Prevention of hyperbilirubinemia: early Prevention of hyperbilirubinemia: early feeds, adequate hydrationfeeds, adequate hydration

• Reduction of bilirubin levels: Reduction of bilirubin levels: phototherapy, phototherapy, exchange transfusion, exchange transfusion,

• Drugs Drugs Use of Phenobarbital promote Use of Phenobarbital promote liver enzymes and protein synthesis.liver enzymes and protein synthesis.

Babies under phototherapy

Baby under conventional phototherapy

Baby under triple unit intense phototherapy

Maisel’s chart

Sr Bilirubin (mg/dl)

Birth weight

Age in hrs

< 24 24 – 48 49 – 72 >72

<5 All

5-9 All Phototherapy if hemolysis

10-14< 2500g Phototherapy

if hemolysis

PHOTOTHERAPY

> 2500gInvestigate if bilirubin

> 12mg%

15-19

< 2500gEXCHANGE

Consider ExchangePhototherapy

> 2500g

All

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Prognosis

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

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phototherapy

• In practice light is used in the white ,blue In practice light is used in the white ,blue and green>and green>

• A dose response relationship exists . A dose response relationship exists . Amount of irradiation directly propotion to Amount of irradiation directly propotion to decrease serum bilirubin .decrease serum bilirubin .

• The energy delivered to infant skin The energy delivered to infant skin decreased with increasing distance decreased with increasing distance between infant and light source (50cm)between infant and light source (50cm)

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phototherapy• Irradiating a large surface area is more Irradiating a large surface area is more

efficient efficient • Nature and character of the light source Nature and character of the light source

e.g (quartz halide spotlight )e.g (quartz halide spotlight )• Fibrostic light is also used in phototherapy Fibrostic light is also used in phototherapy

unit >unit >

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Key point in the practical execution of phototherapy

1- The infant should be naked except for 1- The infant should be naked except for diaper , eye to be covered diaper , eye to be covered

2- distance between the skin and light 2- distance between the skin and light source .source .

3-when used spotlight , the infant is placed 3-when used spotlight , the infant is placed in centre .in centre .

4- routinely add 10-15% extra fluid .4- routinely add 10-15% extra fluid .

5- timing of follow -up S.B testing must be 5- timing of follow -up S.B testing must be indevedualized. indevedualized.

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Adverse effect of photo therapy

• Photo therapy is associated with loose Photo therapy is associated with loose stool .stool .

• Increase risk of retinopathy.Increase risk of retinopathy.• The combination of phototherapy & The combination of phototherapy &

increased S.B can produce DNA strand increased S.B can produce DNA strand breakage .breakage .

• Skin blood flow is increased, redistribution Skin blood flow is increased, redistribution of blood flow may occur – PDA is reported of blood flow may occur – PDA is reported in premature.in premature.

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Adverse effect of phototherapy

• Hypocalcemia appears to be more Hypocalcemia appears to be more common in premature.common in premature.

• Concentration of certain aminoacid may Concentration of certain aminoacid may change.change.

• burn.burn.

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Nursing considerations of Hyperbilirubinemia

• Assessment:Assessment: observing for evidence ofobserving for evidence of

jaundice at regular intervals.jaundice at regular intervals. Jaundice is common in Jaundice is common in

the first week of life and the first week of life and

may be missed in dark skinned may be missed in dark skinned

babiesbabiesBlanching the tip

of the nose

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Approach to jaundiced baby

• Ascertain birth weight, gestation and Ascertain birth weight, gestation and postnatal agepostnatal age

• Ask when jaundice was first noticed Ask when jaundice was first noticed • Assess clinical condition (well or ill)Assess clinical condition (well or ill)• Decide whether jaundice is physiological or Decide whether jaundice is physiological or

pathologicalpathological• Look for evidence of Look for evidence of kernicterus*kernicterus* in deeply in deeply

jaundiced NBjaundiced NB

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

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Nursing diagnosis• See the high risk infant plan of care. See the high risk infant plan of care.

Plus:Plus: Body T.,Body T., risk for imbalanced T. related risk for imbalanced T. related

to use of phototherapy.to use of phototherapy. Fluid volumeFluid volume, risk for deficient related , risk for deficient related

to phototherapy.to phototherapy. Interrupted family process related to Interrupted family process related to

situational crisis, re hospitalization for situational crisis, re hospitalization for the therapy. the therapy.

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The goals of planning

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

o Infant will experience no complications Infant will experience no complications from therapy.from therapy.

o Family will receive emotional support.Family will receive emotional support.o Family will be prepared for home Family will be prepared for home

phototherapy (if prescribed).phototherapy (if prescribed).

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QUESTIONS?

Reference

1-Dr. Nahed Al-Nagger2- manual of neonatal &pediatric intensive

nursing course