Neonatal jaundice overview in Malaysia guideline and settings.

1. Neonatal Jaundice

2. Definition
• Neonatal jaundice refers to yellow discoloration of the skin and the
sclera (whites of the eyes) of newborn babies that results from
accumulation of bilirubin in the skin and mucous membranes. This is
associated with a raised level of bilirubin in the circulation, a
condition known as hyperbilirubinaemia.
• Severe hyperbilirubinemia are at risk of developing Bilirubin-induced
neurologic dysfunction (BIND)

3. Pathogenesis of BIND
• High TSB, High unconjugated bilirubin
not bound to albumin.
• Free bilirubin cross blood brain
barrier causing cell death and
apoptosis of brain tissue.
• Acute bilirubin encephalopathy (ABE)
is reversible, if not treated, may
progress to Chronic Bilirubin
Encephalopathy (CBE), kernicterus.
• Basal ganglia and brainstem nuclei for
oculomotor and auditory function
mostly affected first.

4. Acute Bilirubin Encephalopathy (ABE)
• Early phase
• Sleepy
• high pitch cry
• Mild to
moderate
hypotonia
• Intermediate phase
• Fever, lethargy, poor
sucking, irritable,
jittery,
• high pitch cry,
unconsolable cry,
• Mild to moderate
hypotonia, retrocolis,
opisthotonus with
stimulation.
• Need urgent Exchange
transfusion!
• Advanced phase
• Apnea, irritability to feed,
fever, seizure, comatous
• Hypertonicity, retrocolis
and opisthotonus,
twitching of the limb.
• Inconsolable cry, weak or
absent cry.
• Death due to respiratory
failure or intractable
seizure.

5. Chronic Bilirubin Encephalopathy @
Kernicterus
• Develop during first year after birth
• Choreoathetoid CP
• Sensoryneural hearing loss secondary to neuropathy
• Limitation of upward gaze
• Dental enamel hypoplasia
• 10% mortality 70% long term morbidity

6. Risk Factor
• Prematurity
• Low birth weight
• Jaundice in first 24h of life
• Hemolytic disease
• Mother with blood group O or
rhesus negative (isoimmunisation)
• G6PD deficiency
• Rapid raise of serum bilirubin
• Sepsis
• Hypoalbuminemia
• Lactation failure in Exclusive
breast feeding
• High predischarge bilirubin level
• Cephalhematoma or bruises
• Babies wih diabetic mother
• History of severe jaundice in
siblings

7. BIND Score (Bilirubin induced neurological dysfunction)

8. Method of detection
• Clinical/visual assessment
(Kramer’s rule)
• Transcutanesou Bilirubin
(TcB)
• Serum bilirubin

10. Transcutaneous Bilirubinometer (TcB)
• if TcB levels are more than
200umol/l (12mg/dl), total
serum bilirubin (TSB) should
be obtained.
• TcB is not to be used for
patients on phototherapy.
When measuring the bilirubin level:
– use a transcutaneous bilirubinometer in babies with a gestational age of 35 weeks or more and
postnatal age of more than 24 hours
– if a transcutaneous bilirubinometer is not available, measure the serum bilirubin
– if a transcutaneous bilirubinometer measurement indicates a bilirubin level greater than
250 micromol/litre check the result by measuring the serum bilirubin
– always use serum bilirubin measurement to determine the bilirubin level in babies:
with jaundice in the first 24 hours of life
less than 35 weeks gestational age
– always use serum bilirubin measurement for babies at or above the relevant treatment thresholds
for their postnatal age, and for all subsequent measurements
– do not use an icterometer.
Do not measure bilirubin levels routinely in babies who are not visibly jaundiced.

12. Photolevel

16. Phototherapy • Types of devices: fluorescent tubes, LED,
fibreoptic, halogen bulbs.
• Optimal phototherapy is achieved by optimal
irradiance and adequately esposed body
surface area rather than number of
phototherapy units.
• Distance: 30-50cm from the baby, overhead.
• Babies place in supine position, adequate
exposure
• Cover eyes and frequent review to avoid
complications.
• Allow intermittent breastfeeding.

17. General care during phototherapy
• Place the baby in a supine position unless other clinical conditions prevent
this.
• Give the baby eye protection and routine eye care.
• Use tinted headboxes as an alternative to eye protection in term babies
undergoing conventional
• ‘blue light’ phototherapy.
• Ensure treatment is applied to the maximum area of skin.
• Monitor the baby’s temperature and ensure the baby is kept in a
thermoneutral environment.
• Monitor hydration by daily weighing of the baby and assessing wet
nappies.
• Support parents and carers and encourage them to interact with the baby.

19. Exchange transfusion
Preparations
Procedure
Post management
Complications
• Catheter related
• Infection
• Hemorrhage
• Necrotising
enterocolitis
• Air Embolism
• Vascular events
• Portal, splenic vein
thrombosis (rare)
• Hemodynamic problem
• Overload cardiac
failure
• Hypovolemic shock
• Arrhythmia
• Electrolyte/metabolic
• Hyperkalemia
• Hypokalemia
• Hypo/hyperglycemia
Maintain intensive phototherapy.
Monitor vital signs.
Monitor blood sugar hourly for 2 hour.
Check serum bilirubin 4-6hour after ET
• Consent
• Resuscitation equipment
• Optimize vital signs
• Obtain peripheral IV line
• Proper gentle restrain
• Omit last feed before ET. If <4H,
empty the stomach using NG
aspiration.
• Compatible blood / blood product
Volume: 2x80ml = Total body fluid
Connect the cardiac monitor.
Record baseline observation: apex beat,
respiration, oxygen saturation. Then record every
15 minutes.
Perform under aseptic technique
UVC depth not more 5-7cm in
term infant. Tip should be
proximal to the portal sinus.
Alliquot for removal and
replacement 5-6ml/kg. Max
20ml/cycle. (term)

22. Prolonged jaundice
• >14 days of life in term baby
• >21 days in preterm baby (35-37 weeks)
Unconjugated Conjugated
Septicemia Biliary tree abnormalities
Urinary tract infection - Biliary atresia
Breast milk jaundice - Choledochal cyst
Hypothyroidism - Paucity of bile ducts
Hemolysis - Alagille syndrome, - non syndromic
- G6PD deficiency Idiopathic neonatal hepatitis syndrome
- Congenital spherocytosis Septicemia
Galactosemia UTI
Gilbert syndrome TORCHES – congenital infections
Metabolic disorder
Citrin deficiency
Galactosemia
Progressive familial
intrahepatic cholestasis (PFIC)
Alpha 1 anti trypsin
deficiency

23. Factors that influence the risk of kernicterus
• Identify babies with hyperbilirubinaemia as being at increased risk of developing
kernicterus if they
• have any of the following:
• – a serum bilirubin level greater than 340 micromol/litre in term babies
• – a rapidly rising bilirubin level of greater than 8.5 micromol/litre per hour
• – clinical features of acute bilirubin encephalopathy.
Care for babies with prolonged jaundice
In preterm and term babies with prolonged jaundice (see page 6 for definitions):
– look for pale chalky stools and/or dark urine that stains the nappy
– measure the conjugated bilirubin
– carry out a full blood count, blood group determination, DAT and urine culture
– ensure that routine metabolic screening has been performed.
Follow expert advice about care for babies with a conjugated bilirubin level greater than
25 micromol/litre.

24. Workup

25. References
• Uptodate
• Malaysia Paediatrics Protocol
• NICE Guideline