Neonatal Jaundice

Dr. Abhijeet DeshmukhDNB Pediatrics

PIMS & RC, Tiruvalla

Neonatal Jaundice• Learning 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.

Neonatal Jaundice(Hyperbilirubinemia)

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

• Unconjugated bilirubin = Indirect bilirubin.• Conjugated bilirubin = Direct bilirubin.

NJ - 4

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

NJ - 7

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

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 and urine staining

clothes yellow• Direct bilirubin> 2 mg / dl

Causes of jaundice

Appearing within 24 hours of age• Hemolytic disease of NB : Rh, ABO• Infections: TORCH, malaria, bacterial• G6PD deficiency

Causes of jaundice

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

Causes of jaundiceAfter 72 hours of age• Sepsis• Cephalhaematoma• Neonatal hepatitis• Extra-hepatic biliary atresia• Breast milk jaundice• Metabolic disorders (G6PD).

Breast feeding jaundice

• In exclusively breast feed infants• Appears at 24-48 hrs of age• Peaks by 5-15 days• Disappears by 3rd week• Its related to inadequate B.F• T/t:Proper & adequate B.F

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

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

Diagnostic evaluation:

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

• Investigate the cause of jaundice.

Therapeutic Management

• Purposes: reduce level of serum bilirubin and prevent bilirubin toxicity

• Prevention of hyperbilirubinemia: early feeds, adequate hydration

• Reduction of bilirubin levels: phototherapy, exchange transfusion,

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

Babies under phototherapy

Baby under conventional phototherapy

Baby under triple unit intense phototherapy

Prognosis

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

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 babies

Blanching 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!