About jaundice

1. NEONATA
L
JAUNDI
CE
By roll no. 91 to 95
Guided by Dr.Dhaval Nayak sir
Zydus Medical College and Hospital, Dahod
Department of Pediatrics
APPROACH
TO

2. Objectiv
es
• Definition of jaundice
• Types of jaundice
• Causes of neonatal jaundices
• Management of neonatal
jaundice

3. Neonatal hyperbilirubinemia
Definition :
Jaundice is the yellow color of the skin and sclerae
caused by deposits of bilirubin

4. 1. Increased Bilirubin Load due to a high hemoglobin
concentration.
• The normal newborn infant
• Hemolysis
• Cephalhematoma or bruising , Polycythemia
2. Decreased Bilirubin Conjugation in the liver
3. Defective Bilirubin Excretion
Mechanisms of Neonatal Jaundice

5. EtiologyOf
Jaundice

6. CAUS
ES

7. • Appears after 24 hours
• Total bilirubin rises by less than 5
mg/dl per day
• Maximum intensity by 4th-5th day in
term & 7th day in preterm
• Serum level less than 15 mg / dl
• Clinically not detectable after 14 days
Physiological
Jaundice
Appears within 24 hours of age
• Increase of bilirubin > 5 mg / dl / day
• Serum bilirubin > 15 mg / dl
• Jaundice persisting after 14 days
• Stool clay / white colored and urine
staining yellow
• Direct bilirubin > 2 mg / dl
Pathological
jaundice

8. Breast milk jaundice
– It is caused by prolonged
increased enterohepatic
circulation of bilirubin
– Bilirubin peaks at 10-15
days of age.
– The level of unconjugated
bilirubin is at 10-30 mg/dL
– If nursing is interrupted for
24 hours, the bilirubin level
falls quickly
Breast-milk jaundice;
is the commonest
cause of Prolonged
jaundice in term
infants

9. Pathologic
al
Jaundice

10. Pathological jaundice
1. Appears within 24 hours of age
1. Increase of bilirubin > 5 mg / dl / day
1. Serum bilirubin > 15 mg / dl
1. Jaundice persisting after 14 days
1. Stool clay / white colored and urine staining yellow
1. Direct bilirubin > 2 mg / dl

11. Conjugated
Bilirubin
Pathological
Unconjugated
Bilirubin (indirect)
Hepati
c
Post-
hepatic
Non-
hemolytic
Hemolyti
c
Pathological
Jaundice

12. 1 Unconjugated (Indirect)
hyperbilirubinemia
1. Hemolysis
• Rh , ABO and other blood group incompatibilities
• spherocytos, elliptocytosis, Alpha thalassemia
• Sepsis ,DIC
• Hematomas
• Polycythemia
2. Non hemolytic
• Breast milk jaundice
• Crigler-Najjar syndrome, types I and II
Pathological jaundice

13. 2-Conjugated
hyperbilirubinemia
1. Hepatic
• Idiopathic neonatal hepatitis
• Infections - TORCH, sepsis
• Inborn errors of metabolism
• Galactosemia
• Tyrosinemia
2. Post hepatic
– Biliary atresia, choledochal
cyst

14. Common causes of
jaundice
• Physiological
• Blood group
incompatibility
• G6PD deficiency
• Breast milk jaundice
• Cephalhaematoma
• Infections

16. • Crigler-Najjar syndrome type I - rare
• Complete absence of UDPGT and is characterized by
severe hyperbilirubinemia with the ongoing risk of
kernicterus at any point during an individual's lifespan.
• Currently, liver transplantation is the only definitive
therapy
• Patients with Crigler-Najjar
syndrome type II partial absence of UDPGT
similar to type I but dramatically respond to therapy
with phenobarbital, which is how the diagnosis is made

17. Risk factors for
jaundice
• J - jaundice within first 24 hrs of life or
premature
• A - a sibling who was jaundiced as neonate
• U - unrecognized hemolysis (ABO)
• N nursing – non-optimal sucking/nursing
• D - deficiency of G6PD , DRUGS , Ceftriaxone,
• I - infection
• C – Cephalhematoma /bruising
• E - East Asian/North Indian

18. Approach to jaundiced
baby
1. Determine birth weight, gestation and postnatal age
2. Assess clinical condition (well or ill) ,degree of
jaundice
3. Decide whether jaundice is physiological or
pathological
4. Look for evidence of kernicterus in deeply
jaundiced NB

19. Clinical assessment of
jaundice
Area of body Bilirubin
levels/dlmg
• Face 6
• Upper trunk 9
• Lower trunk & thighs 12
• Arms and lower legs 15
• Palms & soles > 15

21. High bilirubin level
kernicter
us (Bilirubin Encephalopathy)

22. Major Clinical Features of Acute Bilirubin
Encephalopathy
• Lethargy
• Poor sucking
• poor or absent Moro's,
• Retrocollis-
opisthotonos
Convulsions

23. Major clinical features of chronic
bilirubin
encephalopathy
• Athetosis
• Upward gaze
• Sensorineural hearing
loss
• Intellectual deficits, mild
MR

24. Laboratory tests
• Total & direct bilirubin*
• Blood group and Rh for mother and baby*
• Hematocrit, retic count and peripheral smear*
• G6PD assay
• Coomb’s test
• Sepsis screen
• Liver and thyroid function
• TORCH titers
• Liver scan when conjugated hyperbilirubinemia
• Ultrasonography of the liver and bile ducts in cholestasis

25. Measurement
of bilirubin by
jaundice
meter

26. Liver function
tests:
•Aspartate aminotransferase (ASAT or SGOT) and alanine
aminotransferase (ALAT or SGPT) levels are elevated in
hepatocellular disease.
•Alkaline phosphatase and γ -glutamyltransferase (GGT)
levels are often elevated in cholestatic disease.
•A γ -GT/ALAT ratio of more than 1 is strongly suggestive of
biliary obstruction. However, it does not distinguish between
intrahepatic and extrahepatic cholestasis (do ultrasoud)
Reducing substance in urine: is a useful screening test for
galactosemia, provided the infant has received sufficient quantities
of milk.

27. Other
Tests
• Hearing tests (Brainstem auditory-evoked
potentials) should be obtained in aftermath of
severe neonatal jaundice to exclude
sensorineural hearing loss.
• MRI in kernicterus

28. Manageme
nt
1. Phototherapy
2. intravenous immune globulin
(IVIG)
3. Exchange transfusion
4. Drugs

29. Baby under triple unit
intense
phototherapy
Baby under conventional
phototherapy
Baby under triple unit intense
phototherapy

30. Principle of phototherapy
Native
bilirubin
( water
Insoluble)
450-460nm of
light
`Photo isomers of
bilirubin
(water
Soluble)
Urin

31. Phototherapy
Technique
• Perform hand wash
• Place baby naked in cradle or incubator
• Fix eye shades
• Keep baby at least 45 cm from lights
• Start phototherapy
• Frequent extra breast feeding every 2
hourly
• Turn baby after each feed
• Temperature record 2 to 4 hourly
• Weight record- daily
• Monitor urine frequency
• Monitor bilirubin level

33. Side effects of phototherapy
• Increased insensible water loss
• Loose stools
• Skin rash
• Bronze baby syndrome
• Hyperthermia
• May result in hypocalcemia

34. Intravenous immune
globulin
• IVIG in infants with Rh or ABO isoimmunization
can significantly reduce the need for exchange
transfusions.
• Now IVIG has replaced exchange transfusion as
the second-line treatment in infants with
isoimmune jaundice.
• 1 gm/kg/dose IV

35. Exchange
transfusion
• Exchange transfusion is
indicated for avoiding bilirubin
neurotoxicity when other
therapeutic modalities have
failed or are not sufficient.
• the procedure may be indicated
in infants with erythroblastosis
who present with severe
anemia, hydrops, or both, even
in the absence of high serum
bilirubin

36. Phenobarbital (Luminal)
• Hyperbilirubinemia: 3-8 mg/kg/d
PO/IV initially; may increase up to 12
mg/kg/d Not to exceed IV
administration rate of 1 mg/kg/min or
30 mg/min for infants

37. Remember that:
• Jaundice is the most frequent cause of
admission after
early discharge from nursery.
• It is not physiological if: appear in first 24 hrs,
increases by > 0.5 mg/dL/hr , evidence of
hemolysis, abnormal examination, direct bilirubin is
> 20% of total, or persists
> 3 weeks.
• Jaundice present in the first 24 hrs of life must be