NEONATAL JAUNDICE

CONTENTS
 Introduction

 Physiological Jaundice
 Pathological jaundice

 Breastfeeding jaundice
 Breastmilk jaundice
 Clinical examination
 Causes & Risk Factors
 Approach & Management
 Follow up & Prevention
 INTRODUCTION

 Yellowish discoloration of the eyes and skin

 Progresses in cephalocaudal direction
 Incidence: 60% in Terms, 80% in Preterms
 1Hb = 34 mg og Bilirubin
 Complications of Pathological Jaundice: Excess sleepiness,
Poor feeding, seizures, Cerebral palsy, Kernicterus.
 PHYSIOLOGICAL JAUNDICE

 Immaturity to handle increased bilirubin load

 Appears between 24-72 hr of age
 Total serum bilirubin (TSB) peaks by 3 days of age
& then falls
 TSB levels below the cut-offs for phototherapy
 PATHOLOGICAL JAUNDICE
 Elevation of TSB levels where treatment is required
 TSB levels: ≥ 5 mg/ dl on 1st day,
≥ 10 mg/dl on 2nd day, OR
≥ 15 mg/ dl thereafter in term babies
 Appearance of jaundice within 24 hr
 TSB levels above the expected normal range
 Presence of clinical jaundice beyond 3 weeks
 Conjugated bilirubin, being water soluble stains
napkin. (dark urine staining the nappy)
 BREASTFEEDING JAUNDICE
 Appears between 24-72 hr of age

 Peaks by 5-15 days of life

 Disappears by 3rd week of life

 1/3rd of all breastfed babies are detected to have mild clinical

jaundice in 3rd week of life, which may persist into 2nd to 3rd
month of life in a few babies

 Related to inadequate breastfeeding (breastfeeding jaundice)

 Optimum breastfeeding would help to decrease such incidence

 BREAST MILK JAUNDICE

 Unconjugated (not staining nappies); & other causes

for prolongation ruled out (Such as inadequate feeding,
continuing hemolysis, extravasated blood, G6PD
deficiency and hypothyroidism)
 Jaundice in excess of 10 mg/ dl beyond 3rd-4th weeks of
life should be investigated for prolonged jaundice
 Mothers should be advised to continue breastfeeding
at frequent intervals & TSB levels usually decline
over a period of time
 May require phototherapy
 Breastfeeding should not be stopped either for
diagnosis or treatment of breast milk jaundice
 CLINICAL ESTIMATION

 Progresses in a cephalocaudal direction

 Should be examined in good daylight
 The skin of forehead, chest, abdomen, thighs, legs,
palms & soles should be blanched with digital pressure
& the underlying color of skin & subcutaneous tissue
should be noted
 Yellow staining of palms and soles is a danger sign &
requires urgent serum bilirubin estimation and further
management
 TSB can be assessed non invasively by a transcutaneous
handheld device.
DERMAL ZONES FOR ESTIMATION
OF TOTAL SERUM BILIRUBIN
LEVELS
Serum levels of total bilirubin are
approximately:
 4-6 mg/dl (ZONE 1)
 6-8 mg/dl (ZONE 2)
 8-12 mg/dl (ZONE 3)
 12-14 mg/dl (ZONE 4)
 >15 mg/dl (ZONE 5)
 CAUSES
I. HEMOLYTIC:
 Rh incompatibility
 ABO incompatability
 G6PD deficiency
 Thalassemias

 Hereditary spherocytosis
 II. NON-HEMOLYTIC
 Prematurity

 Extravasated blood
 Inadequate feeding
 Polycythernia

 Breast milk jaundice

 Idiopathic
 RISK FACTORS FOR SEVERE HYPER
BILIRUBINEMIA
i. Observed in 1ST 24 hr

ii. Blood group incompatibility with positive direct

antiglobulin test, other known hemolytic disease (e.g. G6PD
deficiency)

iii. Gestational age 35-36 weeks

iv. Previous sibling received phototherapy

v. Cephalohematoma or significant bruising

vi. If breastfeeding is inadequate with excessive weight loss

 MANAGEMENT

Investigations:

1st line:
 TSB only in Physiological MCQ

 TSB & fraction in Pathological jaundice

 Blood groups of mother & baby

 Peripheral smear: Evidence of hemolysis

2nd line:

• Direct Coombs test: detects presence of

antibody coating on fetal RBC

• Hematocrit: ↓ in hemolysis

• Reticulocyte count: ↑ in hemolysis

• G6PD level
 Others:

• Sepsis screen

• Thyroid function test

• Urine for reducing substances to rule out

galactosernia

• Specific enzyme/ genetic studies for Crigler-Najjar,

Gilbert & other genetic enzyme deficiencies
PROLONGED JAUNDICE > 3 WEEKS
 Significant jaundice (10 mg/dl) beyond 3 weeks
 Causes:

Inadequate feeding

Breast milk jaundice

Extravasated blood (cephalohematoma)

Ongoing hemolytic disease

G6PD deficiency

Hypothyroidism
 For dark urine or significant jaundice, Rule Out:

i. Cholestasis (stool color, urine color, direct and

indirect bilirubin levels)

ii. Ongoing hemolysis, G6PD screen

iii. Hypothyroidism

iv. Urinary tract infection

 PHOTOTHERAPY
 Converts insoluble bilirubin (unconjugated) into soluble
isomers  excreted in urine and feces
 The bilirubin molecule isomerizes to harmless forms
under blue-green light (460-490 nm)
 No role for prophylactic phototherapy: For phototherapy
to be effective, Bilirubin needs to be present in skin
Phototherapy acts by several ways:

 Structural isomerization (main mechanism)

Bilirubin Lumirubin (irreversible)

 Configurational isomerization

4Z, 15Z converted to 4Z,15E isomer (reversible), so slow acting

process

 Photo oxidation

Converted to small polar products that are soluble & can easily be
excreted via urine & feces.
ADMINISTERING PHOTOTHERAPY
 Ambient room temperature optimum (25 ° to 28 ° C)
 Remove all clothes except the diaper
 Cover eyes with eyepatch. (Prevents UV keratitis)
 Place the baby under the lights in a cot or bassinet (if >2
Kg), in an incubator or radiant warmer (if <2 kg)
 Distance: As close as possible. ( Previously 30 to 45 cm)
 Optimum breastfeeding
SIDE EFFECTS OF PHOTOTHERAPY

 Dehydration  Electrolyte imbalance

 Transient skin rashes  Increased metabolic rate
 Hyperthermia  Bronze Baby Syndrome
 Loose stools
 EXCHANGE TRANSFUSION

 DVET (Double Volume Exchange Tranfusion): If the

TSB reach to age specific cut-off or if signs of bilirubin
encephalopathy present
 Indications for DVET at birth with Rh isoimmunization:

i. Cord bilirubin ≥ 5 mg/ dl

ii. Cord Hb ≤ 10 g/ dl
 For signs of hydrops or cardiac decompensation in
presence of low hematocrit (<35%)  Partial exchange
transfusion with 50 ml/kg of PRBC (Quickly restore
Oxygen carrying capacity of blood)
 By Pull and Push technique via umbilical venous route
 Umbilical catheter inserted just enough to get free flow
of blood
 FOLLOW UP
 For serum bilirubin 20 mg/dl & those who require
exchange transfusion for neurodevelopmental
outcome.
 Hearing assessment (BERA): At 3 months of age.
 Even very elevated serum bilirubin levels within the
range of 25 to 29 mg/ dl are not likely to result in
longterm adverse effects on neurodevelopment with
prompt Treatment
 PREVENTION
• Anti D (RhoGam) injection to Rh –ve mother after first
obstetrical event(within 72hrs). Dose 150 mcg stat

• Adequate breastfeeding

• Immediate checkup if below knees & elbows

• Follow up of high risk babies like with large

Cephalohematoma after 2-3 days of discharge
 REFERENCE: GHAI ESSENTIAL PEDIATRICS

THANK YOU