neonatal jaundice

Hardi Hussein QaderKirkuk university college of medicine

Neonatal Jaundice

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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.

Billirubin Metabolism

Special characteristic in neonates

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

Special characteristic in neonates

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

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.

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

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Jaundice

Physiological Pathological

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.

NJ - 14

Why does physiological jaundice develop?

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

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

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

Grading of extent of jaundice 1Area of body Billirubin levels

mg/dl (*17=umol)

Face 4-8Upper trunk 5-12Lower trunk & thighs 8-16Arms and lower legs 11-18Palms & soles > 15

Grading of extent of jaundice 2

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

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

Hemolytic disease of newborn

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

Placental barrier• ..

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:

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

The blood types (Rh)

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.

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.

• 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.

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.

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

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Medical ManagementPhototherapy

Phenobarbital Therapy

Metalloporphyrins

Exchange Transfusion

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Phototherapy• When bilirubin > 12 %• Discontinued when level fallen > 2mg/dl of previous.

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TransBilirubin CisBilirubinisomer + Lumibilirubin

By Photoisomerisation

Excreted in the bile & Urine without Conjugation.

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6-8 daylight tubes are mounted on a stand andall electrical outlets are well grounded.At 425- to 475-nm wavelength band

Technique

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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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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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Contraindication :

Liver disease or obstructive jaundice.

Complications :

Watery diarrhoeaSkin rashesDehydrationBronze baby syndromeRetinal damage

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Side effects of phototherapy

•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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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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Metalloporphyrins

bilirubin by inhibiting heme oxygenase

Tin & Zinc are currently used.

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Exchange transfusion

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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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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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• 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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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