NEONATAL JAUNDICE

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NEONATAL JAUNDICE

Learning Objectives:

Define hyperbilirubinemia.
Physiological Vs pathological
jaundice.
causes of hyperbilirubinemia.
pathophysiology of
hyperbilirubinemia.
complications of hyperbilirubinemia.
therapeutic managements options.
plan of care for baby has
hyperbilirubinemia.

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Neonatal Jaundice
Definition:

Hyperbilirubinemia refers
to an excessive level of accumulated
bilirubin in the blood and is
characterized by jaundice, a yellowish
discoloration of the skin, sclerae,
mucous membranes and nails.

Unconjugated

bilirubin.

Conjugated

bilirubin.

bilirubin = Indirect

bilirubin = Direct
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Neonatal
Visible if bilirubinemia
Jaundice
Newborn >5 mg / dl

Occurs

in 60% of term and

80% of preterm neonates
significant jaundice occurs in
6 % of term babies

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Is

it a
diagnosis ?

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EX.1 Neonatal jaundice

Approach: Greeting, Introduce self, Take permission,

thanks
Personal history: Refer to child by name, DOB
,sex,address
Main complain :Onset and duration of jaundice
Associated symptoms (systemic review):Pallor, fever,
Lethargy, poor feeding , vomiting
Feeding history: Breast feeding, artificial feed
Perinatal H\O:Blood group of the mother and baby,
Parity ( primigravida or multigravida ),Maturity ,
gestation (term or PT),H/O premature rupture of
membrane, UTI, vaginal discharge. Color of stool and
urine of baby
Family H\O: Consanguinity,Similar illness in the family,
H/O Phototherapy or exchange transfusion in
Previous sibling/ FH Of hemolytic disease
Investigation:SBR CBC, retic count coomb's test
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A. History
1.

FHO jaundice, anaemia, splenectomy, or early

gallbladder disease suggests hereditary
hemolytic anaemia (e.g., spherocytosis, G6PD
deficiency).
2. FHO liver disease may suggest galactosemia,
1-antitrypsin deficiency, tyrosinosis,
hypermethioninemia, Gilbert disease, CriglerNajjar syndrome types I and II, or cystic fibrosis.
3. Ethnic or geographic origin associated with
hyperbilirubinemia (East Asian, Greek, and
American Indian) .
4. A sibling with jaundice or anaemia may
suggest blood group incompatibility, breastmilk jaundice, or Lucey-Driscoll syndrome.
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 5.

Maternal illness during pregnancy

may suggest congenital viral or
toxoplasmosis infection. IDM tends to
develop hyperbilirubinemia .

6.

Maternal drugs may interfere with

bilirubin binding to albumin, making
bilirubin toxic at relatively low levels
(sulfonamides) or may cause hemolysis
in a G6PD-deficient infant
(sulfonamides, nitrofurantoin,
antimalarials).
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 7.

Labour / trauma associated with

extravascular bleeding and hemolysis.
Oxytocin use may be associated with
neonatal hyperbilirubinemia.

Asphyxiated

infants may have elevated

bilirubin levels caused either by inability of
the liver to process bilirubin or by
intracranial hemorrhage.

Delayed

cord clamping is associated with

neonatal polycythaemia and increased
bilirubin load.
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B. General conditions
1.

Onset of jaundice before 24 hours of

age.
2. Any elevation of serum bilirubin that
requires phototherapy .
3. A rise in serum bilirubin levels of >0.5
mg/dL/hour.
4. Signs of underlying illness in any infant
(vomiting, lethargy, poor feeding,
excessive weight loss, apnoea, tachypnea,
or temperature instability).
5. Jaundice persisting after 8 days in a
term infant or after 14 days in a premature
infant.
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Approach to jaundiced
baby
Ascertain

birth weight, gestation and

postnatal age
When jaundice was first noticed ?
Clinical condition (well or ill) ?
Decide ? physiological or pathological
Look for evidence of kernicterus* in
deeply jaundiced babies .
*Lethargy

& poor feeding, poor or absent

Moro's, or convulsions

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NEONATAL JAUNDICE

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NNJ

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Bilirubin Production & Metabolism

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Hb globin + haem
1g Hb = 34mg bilirubin

Non heme source

1 mg / kg

Bilirubin
Ligandin
(Y acceptor)
Bilirubin
glucuronidase

Intestine

Bil glucuronide

Bil glucuronide

glucuronidase
bacteria
Bilirubin
Stercobilin

Bilirubin

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Clinical assessment of jaundice

(Kramer chart)

Area of body
mg/dl (*17=umol)

Bilirubin levels

Face
4-8
Upper trunk
Lower trunk & thighs
Arms and lower legs
Palms & soles

5-12
8-16
11-18
> 15
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Physiological
jaundice
Characteristics
After

24 hours
Maximum 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.

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Why does physiological

jaundice develop?
Increased

bilirubin load.
Defective uptake from
plasma.
Defective conjugation.
Decreased excretion.
Increased entero-hepatic
circulation.

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Pathological
within 24 hours of age
jaundice
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
Early.HighLate
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Risk factors for

jaundice
JAUNDICE
J

- jaundice within first 24 hrs of life

A - a sibling who was jaundiced as
neonate
U - unrecognized haemolysis
N- non-optimal sucking/nursing
D - deficiency of G6PD
I - infection
C- cephalohematoma /bruising
E - East Asian/North Indian
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SEVERE NNJ

Severe/prolonged (due to
increased retention of
bilirubin in the circulation)
if ;
prematurity
acidosis
hypoalbuminemia
dehydration

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Causes of jaundice
Appearing within 24 hours of
age
Hemolytic

disease of NB : Rh , ABO

Infections:TORCH,

malaria,

bacterial
G6PD

deficiency
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Causes of jaundice
Appearing between 24-72
hours of life

Physiological

Sepsis

Polycythemia

Intraventricular hemorrhage

Increased entero-hepatic
circulation
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Causes of
After 72 hours of age
jaundice
Sepsis
Cephalohaematoma
Neonatal

hepatitis
Extra-hepatic biliary atresia
Breast milk jaundice
Metabolic disorders (G6PD).
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ABCDE

Investigate the cause

Diagnostic
evaluation

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Technology

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Therapeutic
Management

Purposes: reducing serum bilirubin

levels & prevent bilirubin toxicity
Prevention of hyperbilirubinemia:
early feeds, adequate hydration
Reduction of bilirubin levels:
phototherapy, exchange transfusion,
Drugs Use of Phenobarbital
promote liver enzymes and
protein synthesis .
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PHOTOTHERAPY

Conventional phototherapy

Tripple unit intense

phototherapy

Is this baby receiving any

treatment ?

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Intensive
phototherapy

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Double
phototherapy

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A baby among the

lot !

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Disadvantages of
phototherapy ???
6 known complications

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CONJUGATED
HYPERBILIRUBINEMIA
Clinically,

(CHOLESTASIS)

jaundice is green
compared to jaundice due to
unconjugated
1. Hepatocellular diseases:
Neonatal idiopathic
hepatitis
Viral (Hepatitis B, C, TORCH
infections)
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 2.Bacterial

( E. coli, UTI )
3. Total parenteral nutrition
4. Hepatic ischemia (post-ischemic
damage)
5. Erythroblastosis foetalis
(late,Inspissated Bile Syndrome)
6. Metabolic disorders (partial list):
Alpha-1 antitrypsin deficiency
Galactosemia, tyrosinemia,
fructosemia Glycogen storage
disorders Cerebrohepatorenal disease
(Zellweger) Cystic fibrosis
Hypopituitarism
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7.

Biliary tree abnormalities:

A. Extrahepatic biliary atresia: In
first 2 weeks,, unconjugated
bilirubin predominates; elevated
conjugated bilirubin is late.
B. Paucity of bile ducts
(Alagilles vs. non-syndromic)
C. Choledochal cyst
D. Bile plug syndrome
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EVALUATION and
MANAGENMENT
of CHOLESTASIS
1. Initial evaluation:
Total

and direct bilirubin

AST, ALT, GGT, urine reducing substances
Hepatic ultrasound
2. Later evaluation (as indicated):
Hepatitis B and C serology 1antitrypsin deficiency studies
Very long chain fatty acids Brain
sonogram
HIDA scan Cholangiogram
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3.

Management:

Conjugated

bilirubin is not

toxic.
Management is treatment of
cause.
Phototherapy will cause
bronzing with conjugated
hyperbilirubinem
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Nursing considerations of
Hyperbilirubinemia
Assessment:

observing for evidence of

jaundice at regular intervals.
Jaundice is common in
the first week of life and
may be missed in dark skinned
Blanching the tip
babies

of the nose

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Prognosis
Early recognition and

treatment of
hyperbilirubinemia prevents
severe brain damage.

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Nursing diagnosis
See

the high risk infant plan of

care. Plus:
Body T; related to use of
phototherapy.
Fluid balance ; related to
phototherapy.
Interrupted family routine;
related to situational crisis, re
hospitalization for the therapy.
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The goals of
management

Appropriate therapy to
reduce serum bilirubin levels.
o No complications from
therapy.
o E motional support to family.
o Home phototherapy ?

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THANKS
QUESTIONS?
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