1. Jaundice By Bish

3. Differentiate between physiological and pathological jaundice.

4. State causes of hyperbilirubinemia.

5. Describe the most dangerous complication of hyperbilirubinemia.

7. Why am I learning this? Is it important?

8. Why? Jaundice is quite common Full term infants: at least 60% Preterm infants: over 80%

9. Most Importantly…

10. Most Importantly… Kernicterus: unconjugated bilirubin deposits in the brain  yellow staining + degenerative lesions Phase 1: decreased alertness Hypotonia Poor feeding Phase 2: Hypertonia, Retrocollis, opisthotonus Phase 3: Hypotonia

12. Journey through the liver Bilirubin taken up Conjugated to form water soluble conjugate Conjugate secreted into bile

14. In The Gut Bilirubin diglucuronide may be Deconjugated or Metabolised by bacteria to urobilinogenpartially reabsorbed (remainder makes the stool brown)

15. So where can things go wrong?

17. Impaired uptake by hepatocyte Hep/cellular.

18. Failure of Conjugation Hep/cellular.

19. Impaired secretion of conj.bil. Hep/cellular.

21. Classifications Physiological Jaundice Pathological Jaundice

22. Physiological jaundice : 1. General state of baby is well 2. Appears 2-3days 3. Disappears <2 week (term infants) <4 weeks (preterm infants) Pathophysiology increased hematocrit and decreased RBC lifespan immature glucuronyltransferase enzyme system (slow conjugation of bilirubin) increased enterohepatic circulation

23. Pathological Jaundice 1. Appears earlier (first 24 hours of life) 2. Fades >2 weeks (term infants) >4 weeks (preterm infants)

24. Back to our table..let’s break things down into basics..

25. Hint…

26. Good Job!

27. Now that you’re a pro.. You’re called by a nurse for a new admission regarding a baby with elevated bili..what do you want to know

28. Approach to jaundiced baby Get age of baby (hours), gestational age, pregnancy hx, septic risk factors, complications with delivery Assess clinical condition (well or ill) Decide whether jaundice is physiological or pathological Look for evidence of kernicterus* in deeply jaundiced NB *review..what do you look for?

29. Approach to jaundiced baby Get age of baby (hours), gestational age, pregnancy hx, septic risk factors, complications with delivery Assess clinical condition (well or ill) Decide whether jaundice is physiological or pathological Look for evidence of kernicterus* in deeply jaundiced NB *Lethargy and poor feeding, poor or absent Moro's, opisthotonus or convulsions

30. Why does the age (hours) of baby matter?

31. Causes of jaundice Appearing within 24 hours of age Hemolytic disease of NB : Rh, ABO Infections: TORCH, malaria, bacterial Appearing between 24-72 hours of life Physiological G6PD deficiency Dehydration (breast feeding jaundice) Sepsis Polycythemia Concealed hemorrhage Intraventricular hemorrhage Increased entero-hepatic circulation Appearing beyond 1 week Breast milk jaundice Prolonged physiologic jaundice in preterm Hypothyroidism Neonatal hepatitis Conjugation dysfunction - e.g. Gilbert syndrome, Crigler-Najjarsyndrome Inborn errors of metabolism - e.g. galactosemia Biliarytract obstruction - e.g. biliaryatresia

32. What workup/labs do you order

33. Workup Initial laboratory tests Total & direct bilirubin Blood group and Rh for mother and baby CBC/d, reticcount and peripheral smear Coombtest TSH, G6PD screen Conjugated hyperbilirubinemia: AST, ALT, PT, PTT, serum albumin, ammonia, TSH, TORCH screen, septic work-up

34. Treatment?

35. Treatment During pregnancy (if severe) Intrauterine blood transfusion Early delivery After pregnancy Increase feeds (especially in breast feeding jaundice) Phototherapy Exchange transfusion (if severe)

36. Bilirubin chart

37. Side effects of phototherapy Increased insensible water loss Loose stools Skin rash Bronze baby syndrome Hyperthermia Upsets maternal baby interaction

39. Thank You