DrFarhaanaHusainyHasbullah D F h H i H b ll h KlinikKesihatanBukitPayong

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Content
Introduction Whatisjaundice? Whatcangowrong? Causesofjaundice Factorsaffectingseverity Management History Examination Treatment ProlongedJaundice g J
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Introduction
Estimated75%ofbabiesdevelopjaundicewithinthe

firstweekofbirth Majorityarephysiologicaljaundice O h d h l i l Othersareduetopathologicalcauses 2530%ofbabiesrequireclinicalintervention

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Whatisjaundice? j
Apparentclinicallywhenlevelofserumbilirubinrises

above85mmol/l Physiologicaljaundiceisareflectionofbilirubinload totheliverandrateofhepaticexcretion(liver maturity)

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Whatcangowronginjaundice g g j
Kernicterus Hi h Highmortality t lit CerebralPalsy H Hearingloss i l Paralysisofupwardgaze D Dentaldysplasia ld l i Occurswhentheelevated

bilirubincausesbraincelldeath
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CausesofNeonatalJaundice
Physiologicaljaundice &Idiopathicjaundice H HaemolysisduetoABOorRhisoimmunization,G6PD l i d ABO Rhi i i i G6PD

deficiency,drugs P l Polycythaemia h i Sepsise.g.UTI Breasfeedingjaundice Breastmilkjaundice j

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Breastfeedingjaundicev.s Breastfeeding jaundice v s Breastmilk jaundice j

Breastfeedingjaundice I d Inadequatebreastfeedingresultingindehydration t b tf di lti i d h d ti Breastmilkjaundice Causedbycertainenzymesinbreastmilkeg db b lk glucoronidase,pregnanendiol A Associatedwithprolongedjaundice i t d ith l dj di Doesntharmbaby DONTSTOPBREASTFEEDING

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Factorsaffectingseverityof Factors affecting severity of j jaundice

Dehydration L Largeweightlossafterbirth i h l f bi h Cephalohematoma Infantofdiabeticmother Acidosis Asphyxia Intestinalobstruction

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History y
Age P i PreviousinfantswithNNJ,kernicterus,G6PD i f i hNNJ k i G6PD Mothersbloodgroup Gestation Presenceofabnormalsymptoms:difficultyinfeeding,

feedingintoleranceandtemperature

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PhysicalExamination y
GeneralCondition P ll Pallor,presenceofcephalohematoma,petechiae, f h l h hi

hepatosplenomegaly C h l Cephalocaudalprogressionofseverityofjaundice d l i f i fj di Intensityofyellowdiscolorationinskinandmucosa

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ScreeningofNNJusingKramer Screening of NNJ using Kramer Chart

AreaofBody RangeofIndirect Bilirubin l b (mmol/l) 68135 35 85204 136272 I II III HeadandNeck UpperTrunk LowerTrunkand thighs Armsandlowerlegs A dl l Palmsand soles

187306 >306

IV V

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 Jaundicemaybe

detectedbyblanching theskinwithpressureof thethumbandnoting thecolorofunderlying skin

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Whentorefertohospital? When to refer to hospital? ( (Whentoworry?)CPGMOH2003 y )

Onsetofjaundicewithin24hoursoflife S SevereJaundice>340umol/l J di l/l Jaundiceuptolevelofsoleoffeet Rapidriseofserumbilirubin>85umol/l/hour Familyhistoryofsignificanthemolyticdiseaseor

kernicterus Clinicalsignssuggestingotherdiseasee.g.sepsis g gg g g Jaundicebelowumbilicus(RefertoLocalpoliciesfor p phototherapythreshold(Photolevel)) py

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PhototherapyLevel py
HoursofLife LowRisk (>38w +well) 150 205 255 290 310 MediumRisk (>38w+RiskFactor) (3537w+well) ( ) 120 170 205 240 255 HighRisk (3537w+ Risk Factor) ) 85 135 170 190 205 D1(24H) D2(48H) D3(72H) D4(96H) >D4>96 H

RiskFactors: 1.IsoimmuneHemolyticDisease(ABO/Rhesus) 2.Asphyxia 3.Temperature 3 Temperature 4.Acidosis

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5.G6PD 6.Significantlethargy 7.Sepsis 7 Sepsis 8.Albumin<3g/dl

Phototherapy py

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Exchangetransfusion g

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ProlongedJaundice g
Visiblejaundicethatpersistsbeyond14daysoflifein

termor21daysinapretermbaby CausesofProlongedneonataljaundice
ConjugatedHyperbilirubinemia (DirectBilirubinemia) NeonatalHepatitis Syndrome p y Biliary Atresia Choledochal Cyst SepticemiaorUTI Congenital MetabolicDisorder(e.g.galactosemia) M t b li Di d ( l t i ) PostTPN
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Unconjugated Hyperbilirubinemia (IndirectBilirubinemia) SepticemiaorUTI p Hemolysis Breastmilkjaundice Hypothyroidism Galactosemia

InitialManagementofProlonged Initial Management of Prolonged Jaundice

Childunwellor palestool Childwell

Investigateat OPD

InitialInvestigations: SerumBilirubin SerumT4 TSH SerumT4,TSH UrineFEMEandC&S G6PDifnotdoneyet FBC,ReticCount,FBP FBC ReticCount FBP

Admitfor investigations andtreatment

Ifitisconjugated/obstructive(directbilirubinemia)jaundice,admit
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Reference
CPGManagementofJaundiceinHealthyterm

Newborn,MinistryofHealth2003 Newborn MinistryofHealth2003 PaediatricProtocolsforMalaysianHospital2005

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