SEMINAR 6:

APPROACH TO NEONATAL JAUNDICE

Presenters:
Addie
Rabi
Dhoshyini
Yana
 Learning Objectives
• Describe the physiology of bilirubin metabolism in the
newborn period and physiological jaundice
• Classify, investigate and treat neonatal conjugated and
unconjugated hyperbilirubinaemia
• Discuss the causes, investigations and management of
prolong neonatal jaundice
Physiology of bilirubin metabolism in newborn period
Physiology of bilirubin metabolism in newborn period

• more bilirubin produced

• more haemolysis
• RBC life span 70 days ( adult: 120
days)
• bilirubin is produced from the
breakdown of hemoglobin into
unconjugated bilirubin
• which is insoluble in water but
soluble in lipids.
• Unconjugated bilirubin binds to
albumin in the blood for
transport to the liver
• less albumin in neonate
• increase unconjugated bilirubin
in the blood
• free unconjugated bilirubin can
cross the blood–brain barrier,
as it is lipid soluble.
• Unconjugated bilirubin bound
to albumin is taken up by the
liver and conjugated by the
enzyme glucuronyl transferase
to conjugated bilirubin (direct
bilirubin)
• which is water-soluble and
excreted in bile into the
duodenum.
• In adults, conjugated bilirubin
is reduced by gut bacteria to
urobilin and excreted.
• Neonates, however, have less
bacteria in their digestive
tracts, so less bilirubin is
reduced to urobilin and
excreted.
• However in many neonates,
the unconjugated bilirubin is
reabsorbed and returned to
the circulation from the
intestinal lumen (enterohepatic
circulation of bilirubin).
• Contributing to physiologic
hyperbilirubinemia and
jaundice.
 Jaundice
• Can be detected clinically when the level of bilirubin in the
serum rises above 85 umol per liter. (5mg/dl)

Source: Pediatric protocols for malaysian hospital 4th edition

Over 50% of all newborns become visibly jaundice.
Reasons:
– Marked physiological release of haemoglobin level from the
breakdown of red cells because of the high HB concentration at
birth(Hb at birth 14.5-21.5 g/dl)

– Shorter red blood cell life span compared to adult (70:120)

– Hepatic immaturity (less efficient)

– increased enterohepatic circulation

Kenicterus
•encephalopathy resulting from
deposited of unconjugated
bilirubin ( fat-soluble) in basal
ganglion and brainstem nuclei
•acute manifestation: lethargy
and poor feeding, irritability,
increase muscle tone;
opisthotonos, seizure and coma
•later; choreoathetoid, learning
difficulties and sensorineural
deafness
 Physiological jaundice
• Jaundice at 2 days to 2 weeks of age
- no underlying cause
- infant is adapting to the transition from fetal life
 Learning Objectives
• Classify, investigate and treat neonatal conjugated and
unconjugated hyperbilirubinaemia
 Causes of neonatal jaundice
JAUNDICE < 24 HOURS OF AGE
•Haemolytic disorders
– Rh incompatibility
– ABO incompatibility
– G6PD deficiency
– Spherocytosis
– Pyruvate kinase deficiency
•Congenital infection
– TORCHES
JAUNDICE >24 HOURS TILL 2
WEEKS OF AGE
• Physiological jaundice
• Breast milk jaundice
• Infections (UTI, septicaemia)
• Hemolytic disorders (G6PD
deficiency, ABO incompatibility)
• Polycythemia
• Cephalhaematoma,
subaponeurotic haemorrhage
• Crigler-Najjar syndrome
 Classification of jaundice
UNCONJUGATED CONJUGATED
•Physiological or breast milk • Cholestasis (biliary atresia,
jaundice choledocal cyst)
•Infection • Neonatal hepatitis syndrome
•Septicemia • Infections (Hep B, TORCHES)
•Hypothyroidism • Metabolic disorders
•G6PD deficiency (galactosaemia)
•Blood group incompatibility
 How to approach an infant with jaundice?
HISTORY:
• Age of onset
• Previous infants with NNJ,
kernicterus, neonatal death,
G6PD deficiency
• Mother’s blood group
• Gestation
• Presence of abnormal symptoms
such as apnea, difficulty in
feeding, feed intolerance and
temperature instability
PHYSICAL EXAMINATION:
•General condition, gestation and
weight, signs of sepsis, hydration
status
•Signs of kernicterus: lethargy,
hypotonia, seizure, opisthotonus,
high pitch cry
•Pallor, plethora,
cephalhaematoma, subaponeurotic
haemorrhage
•Cephalo-caudal progession of
severity of jaundice (Kramer’s rule)
 Methods of detecting jaundice
• Visual Assessment (Kramer’s rule)
 Investigations:
• Total serum bilirubin
• Direct and indirect bilirubin (>25 μmol/L or >20% of total SB)
• Infant’s and mother’s blood groups
• G6PD testing
• Direct Coombs test
• Full blood count
• Reticulocyte count
• Blood culture, urine microscopy and culture (if infection
suspected)
 Indications for referral to hospital:
• Jaundice within 24 hours of life
• Jaundice below umbilicus (corresponds to serum bilirubin 200-250
μmol/L)
• Jaundice extending to soles of feet
• Family history of significant haemolytic disease of kernicterus
• Any unwell infant with jaundice
• Prolonged jaundice >14 days
• Clinical symptoms/signs suggestive of other disease (sepsis)
TREATMENT OF CONJUGATED AND
UNCONJUGATED
HYPERBILIRUBINEMIA
 UNCONJUGATED
HYPERBILIRUBINEMIA
 Requirements for effective phototherapy

A) Irradiance of phototherapy units should be checked regularly

Irradiance of minimum of 15 µW/cm²/nm for conventional
phototherapy
Irradiance of minimum of 30 µW/cm²/nm for intensive phototherapy

B) Distance of the light source not exceeding 30 - 50 cm from the

baby
 Care of babies during phototherapy

• Babies should be regularly monitored for vital signs

including temperature & hydration status.
• Babies should be adequately exposed.
• Babies’ eyes should be covered to prevent retinal damage.
• Breastfeeding should be continued.
 BHUTANI NOMOGRAM

Can be
used as
predischarg
e
screening
 EXCHANGE TRANFUSION
• There are various methods used in performing ET
• These include , ,
and
 Preparation of infant

• Signed Informed Consent from parent.

• Ensure resuscitation equipment is ready and available.
• Stabilise and maintain temperature, pulse and respiration.
• Obtain peripheral venous access for maintenance IV fluids.
• Proper gentle restraint.
• Continue feeding the child; Omit only the LAST feed before ET.
• If < 4 hours from last feed, empty gastric contents by NG aspiration
before ET.
 Procedure (Exchange Transfusion)

• Volume to be exchanged is 2x the infant’s total blood volume (2x80mls/kg).

• Donor's blood should be as fresh as possible and screened to exclude
CMV, hepatitis B and C and HIV
• Connect baby to a cardiac monitor.
• Take baseline observations and record down on the Neonatal Exchange
Blood Transfusion Sheet.
• The following observations are recorded every 15 minutes:
.
• Doctor performs the ET under aseptic technique using a gown and mask.
• Cannulate the umbilical vein to a depth of NOT > 5-7cm in
a term infant
• Aliquot for removal and replacement – 5-6 mls/ kg
(Not more than 5-8% of blood volume)
•Maximum volume per cycle - 20 mls for term infants, not to
exceed 5 ml/kg for ill or preterm infants.
• At the same time the nurse keeps a record of the amount
of blood given or withdrawn, and medications given
 COMPLICATIONS
• thrombocytopaenia
• hypocalcaemia
• hyperkalaemia
• apnoea
• infection
• hypoglycaemia
• seizure
• catheter malfunction
• leg ischaemia
• cyanosis
• bradycardia
• hypotension
• renal failure
• necrotising enterocolitis
CONJUGATED HYPERBILIRUBINEMIA
• Phototherapy is contraindicated
• Treatment of cause is needed
 Learning Objectives
• Discuss the causes, investigations and management of
prolong neonatal jaundice
 Prolonged jaundice
Prolonged jaundice
• Prolonged jaundice
– Visible jaundice that persisted beyond 14 days of life in
a term baby 21 days in a preterm baby
• Conjugated or Unconjugated
Hyperbilirubinemia?
– Conjugated hyperbilirubinemia if conjugated
bilirubin ≥ 25 µgmol/L or >15% of total bilirubin
Conjugated hyperbilirubinemia –Extrahepatic
cholestasis
•Biliary atresia
– Need early diagnosis
– Prognosis is better if surgery (Kasai operation) done within 60
days of age
– Diagnosis
•Ultrasound
•HIDA
•OTC/liver biopsy
 Breast milk jaundice
• Babies are well and thriving
– Seen in up to 1/3 of breastfed babies
– More severe in the presence of G6PD deficiency
– Can persist up to 4 months of age
 How to follow up prolonged jaundice?
• Treat any treatable conditions
– Biliary atresia
– Hypothyroidism
– UTI
– Syphilis
– Inborn error of metabolisms
• Follow up the baby 4-8 weekly with LFT
• Watch out for worsening LFT/liver cirrhosis/liver failure
• Once investigations for prolonged jaundice done and
the SB is not increasing trend, no need to check regular
SB
Thank You