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Neonatal Jaundice (Wong)
Neonatal Jaundice (Wong)
b. acidosis
The metabolic characteristics of
bilirubin continued
3. Bilirubin metabolism of hepatocyte
a. Hepatic uptake of bilirubin
b. Bilirubin conjugation:
UDPGT (uridine diphosphate
glucoronyl transferase)
c. Defective bilirubin excretion
ability to bile system
4. Enterohepatic circulation
Physiological jaundice
• Appears after 24 hours
• Maximum intensity by 4th-5th day in term & 7th
day in preterm
• Unconjugated hyperbilirubinaemia (below
phototherapy level)
• Clinically not detectable after 14 days
• Well baby
9
Course of physiological jaundice
15
Bilirubin level
10
mg/dl
Term
Preterm
1 2 3 4 5 6 10 11 12 13 14
Age in Days
10
Pathological jaundice
1. Appears within 24 hours of age
2. Increase of bilirubin > 8.5 µmol/l per hour
(0.5 mg/dl per hour) or 85 µmol/l per day(5
mg / dl per day)
3. Serum bilirubin > 340 µmol/l (20 mg / dl)
4. Jaundice persisting after 14 days
5. Direct bilirubin> 34 µmol/l (2 mg / dl) or
more than 15% of total bilirubin
11
Causes of jaundice
Appearing within 24 hours of age
• Hemolytic disease of NB : Rh, ABO, G6PD deficiency
• Infections: TORCH, bacterial
12
Acute bilirubin encephalopathy
Decreased alertness
Hypotonia
Poor feeding
Hypertonia,
Retrocollis, opisthotonus
Seizures
Kernicterus
High mortality 10%
Survivors usually suffer sequelae 70%
athetoid cerebral palsy
intellectual disability
high frequency hearing loss
Risk factors for severe jaundice
• Preterm infants
• Small for gestational age
• Sepsis
• Acidosis
• Asphyxia
• Hypoalbuminaemia
• Jaundice < 24 hours of age
Risk factors for severe jaundice
Maternal blood group O/ Rhesus –ve
Infant of diabetic mother
G6PD deficiency
Inadequate breastfeeding
Dehydration
Siblings with severe NNJ or exchange
transfusion
Screening and detection of NNJ
Antenatal care
Education on NNJ to all expectant mother
All mothers have blood taken for ABO and
rhesus blood group
Identify risk factors for significant jaundice
e.g. family history of severe NNJ, exchange
transfusion and haemolytic diseases
Screening and detection of NNJ
Intrapartum care
Take cord blood for G6PD screening
Obtain G6PD results before discharged and
document in home based child health card
If G6PD deficiency, baby admitted for observation
for at least 5 days
If mother Rh –ve, direct coombs test, ABO and Rh
blood type, bilirubin and haemoglobin level of
infant’s (cord) blood required
Screening and detection of NNJ
Postnatal care
Education on NNJ reinforced
Support mother to breastfeeding
adequately. Supplements may be needed
temporarily to ensure adequate hydration.
Actively look for signs of jaundice during
routine care
If jaundice detected, serum bilirubin should
be done and managed appropriately.
Home visit during postnatal period
Blanching
of skin with
finger
pressure
under good
lighting
31
Treatment
Phototherapy
Conventional phototherapy
Intensive phototherapy
Exchange transfusion
Intravenous immunoglobulin
Phototherapy
Conventional phototherapy with blue green
spectrum (wavelength 430-490nm) should be
maintained with minimum irradiance 30
µW/cm2 per nm
Intensive phototherapy using LED
Position light source 35-50cm from top of infant
Expose infant appropriately
Cover infant’s eye
Phototherapy (cont)
Monitor infant’s temperature 4 hourly to avoid
chilling or overheating
Ensure adequate hydration through
breastfeeding (8-10 x/24 hours).
Supplements may be needed temporarily
Monitor urine output
Allow parent-infant interaction
Check serum bilirubin as indicated
Side effects of phototherapy
Hyperthermia/ Hypothermia
Diarrhoea
Skin rash
Bronze baby syndrome (conjugated
bilirubin >4mg/dl)
Indications for intensive phototherapy
Haemodynamic problems
Overload cardiac failure
Hypovolaemic shock
Electrolyte imbalance
High potassium
Low calcium
High or low blood sugar
Acidosis
Intravenous immunoglobulin
High dose immunoglobulin (IVIG) 0.5-
1g/kg single dose has been shown to
reduce need for ET in Rh and ABO
haemolytic disease.
Can be given as early as possible if ET
no yet indicated but TSB rising despite
intensive phototherapy
Breastfeeding jaundice and
breast milk jaundice
Breastfeeding jaundice
Inadequate breast milk flow
Infants may be dry with more than 10% weight loss in from
birth weight
Supplementary feed may be needed temporarily to ensure
adequate hydration
Any questions?