Neonatal jaundice 2 Neonatal jaundice1 3 Acknowledgements4 ...
Neonatal Jaundice - gmch.gov.in lectures/Pediatrics/jaundice.pdf · Teaching Aids: NNF NJ - 2...
Transcript of Neonatal Jaundice - gmch.gov.in lectures/Pediatrics/jaundice.pdf · Teaching Aids: NNF NJ - 2...
Neonatal Jaundice
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Neonatal Jaundice
Visible form of bilirubinemia – Adult sclera >2mg / dl– Newborn skin >5 mg / dl
Occurs in 60% of term and 80% of preterm neonatesHowever, significant jaundice occurs in 6 % of term babies
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Hb → globin + haem1g Hb = 34mg bilirubin
Non – heme source1 mg / kg
Bilirubin glucuronidase
Bilirubin
BilirubinLigandin(Y - acceptor)
Bil glucuronide
Intestine
Bil glucuronide
Stercobilin
bacteria
β glucuronidase
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Clinical assessment of jaundice
Area of body Bilirubin levelsmg/dl
Face 4-8Upper trunk 5-12Lower trunk & thighs 8-16Arms and lower legs 11-18Palms & soles > 15
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Physiological jaundice
CharacteristicsAppears after 24 hoursMaximum intensity by 4th-5th day in term & 7th day in pretermSerum level less than 15 mg / dlClinically not detectable after 14 daysDisappears without any treatment
Note: Baby should, however, be watched for worsening jaundice
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Why does physiological jaundice develop?
Increased bilirubin loadDefective uptake from plasmaDefective conjugationDecreased excretionIncreased entero-hepatic circulation
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Age in Days
TermPreterm
1 2 3 4 5 6 10 11 12 13 14
15
10
5
Bili
rubi
n le
vel
mg/
dl
Course of physiological jaundice
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Pathological jaundice
Appears within 24 hours of ageIncrease of bilirubin > 5 mg / dl / daySerum bilirubin > 15 mg / dlJaundice persisting after 14 daysStool clay / white colored and urine staining clothes yellowDirect bilirubin> 2 mg / dl
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Causes of jaundice
Appearing within 24 hours of ageHemolytic disease of NB : Rh, ABOInfections: TORCH, malaria, bacterialG6PD deficiency
Appearing between 24-72 hours of lifePhysiologicalSepsisPolycythemiaConcealed hemorrhageIntraventricular hemorrhageIncreased entero-hepatic circulation
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Causes of jaundiceAfter 72 hours of age
SepsisCephalhaematomaNeonatal hepatitisExtra-hepatic biliary atresiaBreast milk jaundiceMetabolic disorders
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Risk factors for jaundice
JAUNDICEJ - jaundice within first 24 hrs of lifeA - a sibling who was jaundiced as neonate U - unrecognized hemolysisN – non-optimal sucking/nursingD - deficiency of G6PDI - infectionC – cephalhematoma /bruisingE - East Asian/North Indian
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Common causes in India
Exaggerated physiologicalBlood group incompatibility – ABO,RhG6PD deficiencyBruising and cephalhaematomaIntrauterine and postnatal infectionsBreast milk jaundice
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Approach to jaundiced baby
Ascertain birth weight, gestation and postnatal ageAsk when jaundice was first noticed Assess clinical condition (well or ill)Decide whether jaundice is physiological or pathologicalLook for evidence of kernicterus* in deeply jaundiced NB
*Lethargy and poor feeding, poor or absent Moro's, opisthotonus or convulsions
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Workup
Maternal & perinatal historyPhysical examinationLaboratory tests (must in all)*– Total & direct bilirubin*– Blood group and Rh for mother and baby*– Hematocrit, retic count and peripheral smear*– Sepsis screen– Liver and thyroid function– TORCH titers, liver scan when conjugated
hyperbilirubinemia
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Management
Rationale: reduce level of serum bilirubin and prevent bilirubin toxicityPrevention of hyperbilirubinemia: early feeds, adequate hydrationReduction of bilirubin levels: phototherapy, exchange transfusion, drugs
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Principle of phototherapy
Native bilirubin Photo isomers of bilirubin
Insoluble Soluble
450-460nm
of light
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Phototherapy equipment
White light tubes 6-8*/ 4 blue light tubesCradle or incubatorEye shades
*May use 150 W halogen bulb
Babies under phototherapy
Baby under conventional phototherapy
Baby under triple unit intense phototherapy
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Phototherapy
TechniquePerform hand washPlace baby naked in cradle or incubatorFix eye shadesKeep baby at least 45 cm from lights, if using closer monitor temperature of babyStart phototherapy
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Phototherapy
Frequent extra breast feeding every 2 hourlyTurn baby after each feedTemperature record 2 to 4 hourlyWeight record- dailyMonitor urine frequencyMonitor bilirubin level
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Side effects of phototherapy
Increased insensible water lossLoose stoolsSkin rashBronze baby syndromeHyperthermiaUpsets maternal baby interaction May result in hypocalcemia
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Choice of blood for exchangeblood transfusion
ABO incompatibility– Use O blood of same Rh type, ideal O cells
suspended in AB plasmaRh isoimmunization– Emergency 0 -ve blood
Ideal 0 -ve suspended in AB plasma or baby's blood group but Rh -ve
Other situations– Baby's blood group
Phototherapy
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Exchange Transfusion
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Prolonged indirect jaundice
Causes
Crigler Najjar syndrome
Breast milk jaundice
Hypothyroidism
Pyloric stenosis
Ongoing hemolysis, malaria
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Conjugated hyperbilirubinemia
SuspectHigh colored urineWhite or clay colored stool
CautionAlways refer to hospital for investigations so that
biliary atresia or metabolic disorders can bediagnosed and managed early
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Conjugated hyperbilirubinemia
Causes Idiopathic neonatal hepatitisInfections -Hepatitis B, TORCH, sepsisBiliary atresia, choledochal cystMetabolic -Galactosemia, tyrosinemia, hypothyroidismTotal parenteral nutrition