discussing important points in neonatal Jaundice

1. Hardi Hussein Qader
Kirkuk university college of medicine
Neonatal Jaundice

2. Definition
• Yellow discoloration of the skin and the mucosa
due to accumulation of excess of bilirubin in the
tissue and plasma in neonates. (more than
5mg/dl).
30-50 % of term
newborn
And 80% of
preterm newborns.
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3. Billirubin Metabolism

4. Special characteristic in neonates
•1.More billirubin produced
• Much more Hemolysis
• The life-length of hemolysis(70~80)

6. Special characteristic in neonates
•2.The low capability of albumin on
unconjugated billirubin transportation
• acid intoxication
• Less albumin in neonates

8. Special characteristic in neonates
•3.The low capability of heptatocyte
• Less Y protein and Z protein
• The primary development of Hepato-enzyme system
• Easy-broken hepato-enzyme system
• After-born, the blood glucose level is very low.

10. Special characteristic in neonates
• 4.High workload of the hepato-enteric circulation
• Less bacterial
• Low enzymatic activity in intestine
• High level of billirubin in
meconium

12. Jaundice
Physiological Pathological
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13. NJ - 13
Physiological jaundice
• Characteristics
•Appears after 24 hours
•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
•Disappears without any treatment
• Note: Baby should, however, be watched for
worsening jaundice.

14. NJ - 14
Why does physiological
jaundice develop?
•Increased bilirubin load.
•Defective uptake from plasma.
•Defective conjugation.
•Decreased excretion.
•Increased entero-hepatic circulation.

15. NJ - 15
Pathological 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 clothes
yellow
•Direct bilirubin> 2 mg / dl

18. The general symptom of neonatal
jaundice
• Yellow skin
• Yellow eyes(sclera)
• Sleepiness
• Poor feeding in infants
• Brown urine
• Fever
• High-pitch cry
• Vomiting

19. Grading of extent of jaundice 1
Area of body Billirubin levels
mg/dl (*17=umol)
Face 4-8
Upper trunk 5-12
Lower trunk & thighs 8-16
Arms and lower legs 11-18
Palms & soles > 15

20. Grading of extent of jaundice 2

21. Breast feeding jaundice
• In exclusively breast feed infants
• Appears at 24-48 hrs of age
• Peaks by 5-15 days
• Disappears by 3rd week
• Its related to inadequate B.F
• T/t:Proper & adequate B.F

22. Breast milk jaundice
• In 2-4 % EBF babies
• SBr>10mg/dl beyond 3rd-4th week
• Should be differentiated from Hemolytic jaundice, hypothyroidism,
G6PD def
• T/t: Some babies may require PT
Continue breast feeding
Usually declines over a period of time

24. Hemolytic disease of newborn
This condition occurs
when there is an
incompatibility between
the blood types of the
mother and baby.

25. Placental barrier
• ..

26. The blood types(A, B, O, AB)
• Although it is not as common (especially in a first pregnancy), a
similar problem of incompatibility may happen between the blood
types (A, B, O, AB) of the mother and baby in the following situations:

27. The blood types(A, B, O, AB)

28. The blood types (Rh)

29. Kernictrus (Bilirubin Encephalopathy)
• Lipid-soluble, unconjugated, bilirubin fraction is toxic to the
developing central nervous system
• indirect bilirubin is deposited in brain cells and disrupts neuronal
metabolism and function, especially in the basal ganglia.
• Indirect bilirubin may cross the blood-brain barrier because of its lipid
solubility.
• disruption of the BBB permits entry of a bilirubin-albumin or free
bilirubin–fatty acid complex.

30. Risk factors
• in term infants when bilirubin levels 20 to 25 mg/dL, but the
incidence increases as serum bilirubin levels exceed 25 mg/dL
• Less than 20 mg/dl in presence of sepsis, meningitis, hemolysis,
asphyxia, hypoxia, hypothermia, hypoglycemia, bilirubin-displacing
drugs (sulfa drugs), and prematurity.
• hemolysis, jaundice noted within 24 hours of birth
• delayed diagnosis of hyperbilirubinemia.
• Kernicterus has developed in extremely immature infants weighing
less than 1000 g when bilirubin levels are less than 10 mg/dL because
of a more permeable blood-brain barrier associated with prematurity.

31. • The earliest clinical manifestations of kernicterus are
• lethargy,
• hypotonia,
• irritability,
• poor Moro response,
• and poor feeding.
• A high-pitched cry and emesis also may be present.
• Early signs are noted after day 4 of life.
• Later signs include bulging fontanelle, opisthotonic posturing, pulmonary
hemorrhage, fever, hypertonicity, paralysis of upward gaze, and seizures.

32. Outcome :
• Infants with severe cases of kernicterus die in the neonatal period.
• Spasticity resolves in surviving infants, who may manifest later nerve
deafness,
• choreoathetoid cerebral palsy,
• mental retardation,
• enamel dysplasia, and discoloration of teeth as permanent sequelae.

33. Prevention:
• avoiding excessively high indirect bilirubin levels and by avoiding
conditions or drugs that may displace bilirubin from albumin.
• Early signs of kernicterus occasionally may be reversed by
immediately instituting an exchange transfusion

34. Medical Management
Phototherapy
Phenobarbital
Therapy
Metalloporphyrins
Exchange
Transfusion
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35. Phototherapy
• When bilirubin > 12 %
• Discontinued when
level fallen > 2mg/dl of
previous.
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36. TransBilirubin CisBilirubinisomer + Lumibilirubin
By Photoisomerisation
Excreted in the bile & Urine without Conjugation.
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37. 6-8 daylight tubes are mounted on a stand and
all electrical outlets are well grounded.
At 425- to 475-nm wavelength band
Technique
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38. Baby is placed naked 45 cm away from the tube lights in a
crib or incubator.
Eyes are covered with eye-patches to prevent damage to
the retina by the bright lights; gonads should also be
covered.
Phototherapy is switched on.
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39. Baby is turned every two hours or after each feed.
Temperature is monitored every two to four hours.
Weight is taken at least once a day.
More frequent breastfeeding.
Urine frequency is monitored daily.
Serum bilirubin is monitored at least every 12 hours.
Phototherapy is discontinued if two serum bilirubin
values are < 10 mg/dl.
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40. Contraindication :
Liver disease or obstructive jaundice.
Complications :
Watery diarrhoea
Skin rashes
Dehydration
Bronze baby syndrome
Retinal damage
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41. Side effects of phototherapy
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•Increased insensible water loss: Frequent Breast feeding.
•Loose green stools: weigh often and compensate with
breast milk.
•Skin rashes: Harmless, no need to discontinue
phototherapy.
•Bronze baby syndrome: occurs if baby has conjugated
hyperbilirubinemia. If so, discontinue phototherapy.
•Hypo or hyperthermia: monitor temperature frequently.

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43. Phenobarbital Therapy
ligandin in liver
Induces hepatic enzymes
billirubin conjugation & excretion
Dose: 10mg/kg Day 1 (loading dose)
5-8 mg/kg/day 4 days (maint. dose)
Or to Mother 2 weeks prior delivery.
Dose: 90 mg/day.
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44. Metalloporphyrins
bilirubin by inhibiting heme oxygenase
Tin & Zinc are currently used.
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45. Exchange transfusion
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46. Indications:
Rise of bilirubin >1mg/dl/hour
To improve anemia & CCF
Sr. Bilirubin > 20mg/dl in first 24 hrs
Cord hemoglobin is < 12mg/dl & bilirubin is > 5mg/dl
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47. The procedure involves the incremental removal of the
patient's blood and simultaneous replacement with
fresh donor blood, saline or plasma.
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48. • The patient’s blood is slowly drawn out
• And an equal amount of fresh, prewarmed blood,
plasma or physiologic saline is transfused.
• The cycle is repeated until a predetermined volume of
blood has been replaced.
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49. Risk and Complications
• Cardiac and respiratory disturbances
• Shock due to bleeding or inadequate replacement of
blood
• Infection
• Clot formation
• Rare but severe complications include: air embolism,
portal hypertension and necrotizing enterocolitis
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