ICTERUS

NEONATORUM
Presented by:
Ms. Sharon Vincent
II yr MSc Nursing
 INTRODUCTION
 Jaundice is a yellow discoloration of the skin,
sclera and mucus menbrane caused by
hyperbilirubinemia.
 The newborn appear jaundice when level is
>5mg/dl.
 Jaundice usually becomes visible at
 Sclera -2 to 3 mg/dL
 Face - 4 to 5 mg/dL
 Umbilicus -15 mg/dL
 Feet - 20 mg/dL.
 INCIDENCE

25-60 % of full term newborns

develop clinical jaundice
75-85% of preterm infants
3% of normal term infants show
bilirubin levels > 15mg/dl
 FETAL BILIRUBIN METABOLISM
 Bilirubin can be be detected in normal
amniotic fluid from 12 weeks of GA
and disappears by 36 to 37 weeks .
 Uridine diphosphoglucoronosyl
transferace activity in 0.1 % fetal
liver, reaches to 1% of adult value by
term gestation.
 The major route of fetal bilirubin
excretion is across the placenta.
 BILIRUBIN
METABOLISM
 TYPES
Physiological jaundice
Pathological jaundice
Breast feeding jaundice
Breast milk jaundice
 Physiological jaundice
 In term neonates: TSB reaches to 5-
6 mg/dl by 48 to 120 hours of age.
 10-14 mg/dl at 72-120 hours of age.
 Rapid decline to approx 3mg/dl by
fifth day of life.
 This is designated as a phase I
physiological jaundice.
 From the 5-10 th day of life TSB
concentration decline slowly reaching
the normal adult value of less than
2mg/dl phase 2 physiological
jaundice.
 In preterm neonate: jaundice is more
severe with mean peak TSB
concentration reaching 10 to 12
mg/dl by the fifth day of life
 Pathological jaundice

 Clinicaljaundice appearing in
the first 24 hours. It
increases in the level of TSB
by more than 0.5 mg/dl /hr
or 5mg/dl/24 hours
 CAUSES
 Fetomaternal blood group incompatibility –
Rh, ABO
 Hereditary spherocytosis
 G6PD deficiency

 Vitamin induced hemolysis

 Sepsis
 Enterohepatic circulation
 Pyloric stenosis

 Large bowel obstruction

 Hypothyroidism
 Breast feeding jaundice
 Occur in the I week of life in the breast feed
neonates.
 Maternal factors like lack of proper
technique, breast engorgement , cracked
nipple .
 Neonatal factors like ineffective and some
congenital anomalies like cleft lip and palate.
 All these leads to dehydration and delayed
passage of meconium. Leads to increase in
enterohepatic reuptake of bilirubin leading to
unconjugated hyperbilirubinemia.
 BREAST MILK JAUNDICE
 Occur during 2-3 weeks of life
beyond upto 3 months of age.
 Usually TSB reches a peak of 5 to 10
mg/dl at approximately 2 weeks of
life or beyond upto 3 months of age.
 Pregnadiol a progestrone metabolism
found in the breast milk was thought
to be the cause of the disorder.
RULE OF FIVE TO ASSESS JAUNDICE

 I - 5mg/dl
 II-10 mg/dl

 III- 12 mg/dl
 IV- 15 mg/dl

 V- >15 MG/dl
 KERNICTERUS (CHRONIC
BILIRUBIN ENCEPHALOPATHY
 Kern: nuclear region of the brain
and
 Icterus – jaundice
 Kernicterus is brain damage caused
by unconjugated bilirubin deposition
in basal ganglia and brain stem
nuclei, caused by either acute or
chronic hyperbilirubinemia.
 Causes
Bilirubin can cross the blood-brain barrier in
certain situations:
 When serum bilirubin concentration is
markedly elevated >20mg/dl
 When serum albumin concentration is
markedly low (eg, in preterm infants)
 When bilirubin is displaced from albumin by
competitive binders (eg, sulfisoxazole ,
ceftriaxone , aspirin and free fatty acids
and hydrogen ions eg, in fasting, septic, or
acidotic infants).
 Clinical features

 Extrapyramidal disturbances especially

athetosis (slow, purposeless, and
involuntary movements of the hands,
feet, face, tongue, and neck as well as
other muscle groups).
 Auditory abnormalities especially
sensori neural hearing loss
 Gaze palsies especially upward gaze

 Dental dysplasia
 Clinical Features Of Bilirubin
Encephalopathy

Initial Intermedi Advance

phase ate phase d phase
●
slight stupor ●
Moderate
●
Deep stupor
●
(lethargy stupor to coma
,sleep) ●
Tone variable , ●
Tone usually
●
Slight opisthotonus increased
hypotonia
●
Minimal ●
No feeding
Poor sucking feeding
●
shrill cry
 INVESTIGATIONS
 History
 Transcutaneous bilirubinometry
 Total serum bilirubin
 Blood type and Rh

 Direct antiglobulin test (DAT) in the

infant (direct Coombs test)
 Hb, PCV

 Serum albumin levels

 Liver function tests
 Nomogram for hour-specific bilirubin values
 Measurement of End-tidal carbon monoxide
in breath (ETCO
 Peripheral blood film for erythrocyte
morphology
 Reticulocyte count
 Conjugated bilirubin levels:

 Thyroid function test

 Ultrasonography

 Radionuclide scanning
 Tests for viral and/or parasitic infection
 MANAGEMENT
PHYSIOLOGIC JAUNDICE
 no specific treatment required

 continue breast feeding

 watch for sudden rise in bilirubin
levels
 treat any exaggerating factors.
 PATHOLOGIC JAUNDICE
 Increase feeds in volume and calories. Early
feeding lowers serum bilirubin level by
stimulating the peristalsis.
 Stop drugs interfering with bilirubin
metabolism.
 Correct hypoxia, infection, and acidosis.
 Phototherapy
Prophylactic: in LBW or bruised neonate.
Therapeutic.
Exchange transfusion.
Phenobarbitol

Agar-Agar

Albumin infusion
Tin protoporphyrin
 Phototherapy
It consists of the application of
fluorescent light (blue or
white) to the newborns skin.
Light causes break down of
bilirubin by the process of
photo oxidation.
Indications of phototherapy:
It is used when bilirubin level
is:
 5-9 mg/dl at the 1st day of life.
 9-15 mg/dl at the 2nd day of
Side effects of phototherapy:
 Dehydration due to increased insensible
water loss.
 Watery diarrhea.
 Hypocalcemia.

 Retinal damage.

 Erythema and skin rashs.

 Bronze baby syndrome.

 Maternal newborn interaction is affected.

 Dark yellow urine.
 Nurse’s responsibility in phototherapy:

 The lamp should be 5-8 cm over the

incubator.
 Continue the feeding.
 Shield the newborn’s eyes, genetalia
 change position frequently.

 Cleanse skin frequently to prevent irritation.

 prevent dehydration and calculate intake and

output.
 Check newborn’s body
temperature every four
hours.
 Weight newborn daily.

 Observe skin, mucous

membranes, and stool.
 Bilirubin levels should be
followed for at least 24
hours after discontinuing
phototherapy.
 EXCHANGE TRANSFUSION
 It is an ideal dilution of S. Bilirubin and
antibodies. A catheter is introduced into the
umbilical vein after cutting the cord. Through
a special valve, the umbilical catheter is
connected with the donor blood. Exchange is
carried out over 45-60 min period by
alternating aspiration of 20 ml of newborn’s
blood and infusions of 20 ml of the donor
blood.
Exchange transfusion
 Indication
 Despite phototherapy progressive
rise of bilirubin>1mg/dl/hr
 To improve anemia and CCF of
neonate
 Serum bilirubin ≥ 20mg/dl

 Cord blood HB < 12 mg/dl &

bilirubin> 5mg/dl
 Complications:
 Embolism, thrombosis, infarction.
 Arrhythmias, heart failure, arrest.
 Electrolyte disturbances.

 Thromobocytopenia.
 Infections
 Hypo and hyperthermia.
Nursing responsibilities:
 Keep the newborn NPO for 2-4 hours
before exchange to prevent aspiration.
 Check donor blood charts
compatibility.
 Keep resuscitation equipment at
bedside: oxygen, ambu bag,
endotracheal tubes, and laryngoscope.
 Assist physician with exchange
transfusion procedure.
 Track amount of blood withdrawn
and transfused to maintain
balanced blood volume.
 Maintain body temperature to avoid
hypothermia and cold stress.
 Monitor vital signs and observe for
rash.
 After transfusion, continue to
monitor vital signs and check
umbilical cord for bleeding or signs
of infection.
 PHENOBARBITAL
 Mechanism of Action: induces activity
of enzyme glucoronyl transferase and
increases bilirubin conjugation and
excretion.
 Dosage: therapeutic- 5-8mg/kg/day to
newborn indicated only in Crigler Najjar
syndrome type II & other conjugated
hyperbilirubinemia.
 Side-Effects: drowsy child, slow
feeding.
AGAR
 Mechanism of Action: binds
bilirubin to gut and diminishes
enterohepatic circulation.
Dosage: 125mg/ 3 hrly
in mild to moderate
hyperbilirubinemia.
 TIN PROTOPORPHYRIN:
hemeoxygenase enzyme inhibitor.
ALBUMIN INFUSION
 Mechanism of Action: raises bilirubin
binding capacity.
 Dosage: 1mg/kg of salt free albumin can
be used as an alternative for exchange
transfusion.
BREAST MILK JAUNDICE
Interruption of breastfeeding for 24-48
hours and feeding with breast milk
substitutes often helps to reduce the
bilirubin level.

NURSING DIAGNOSIS
 Risk for injury from breakdown products of red
blood cells in greater numbers than normal and
functional immaturity of liver
 Altered family processes related to maturational
crisis, birth of term infant, change in family unit
 
REFERENCE
 Singh M .Care of Newborn.6th edition. Published by Narinder
K. Sagar: NewDelhi; 2004
 Gupta Piyush . Essential paediatric Nursing . 1st edition .AP
Jain & Co. NewDelhi; 2004
 Gupta Suraj .Recent advancesin Paediatrics.1st edition. Jaypee
publication : NewDelhi; 1991
 Desai VJ, Avalokitha B. Achar’s text book of Pediatrics, 3rd
edition, Madras, Orient Logmon Limited; 1991
 Parthasarathy A, Menon PSN, Nair MKC. IAP text book of
pediatrics. 2nd edition. New Delhi: Jaypee publishers;2000
 http://www.ncbi.nlm.nih.gov/pubmed/19000294
 http://emedicine.medscape.com/article/974786-overview