Neonatal Jaundice

Anis binti ab wahab

CME
4/3/18
 Outlines
• Definition
• Type
• Risk factor
• Approach
• Clinical assessment
• Management
• Exchange tranfusion
• Prolong jaundice
 DEFINITION
• Neonatal – first 28 days after
birth.
• Jaundice – yellowish
discoloration of the sclera,
mucous membrane and skin
due to hyperbilirubinemia.
• Neonatal jaundice is important
because:
– It maybe a sign of another
disorder.
– Unconjugated bilirubin can be
deposited in the brain especially
basal ganglia → kernicterus.
 Neonatal jaundice
• Detected clinically when the level of bilirubin
are >85umil/L(5mg/dl)
 Type of jaundice

Physiological Pathological
Jaundice Jaundice
 Physiological jaundice
• Exessive bilirubin production-higher bilirubin
content and shorter RBC life span and poor
bilirubin clearance (liver immaturity)
• Appears 2-4days of live, resolving one-2 weeks
(3 weeks in preterm)
• Not associated with underlying disease and is
usually benign.
 Risk factors for severe NNJ
• Prematurity
• Low birth weight
• Jaundice in 24 hrs of life
• Mother blood group O/rhesus negative
• G6PD deficiency
• Rapid rise in TSB
• Sepsis
• Lactation failure in exclusive breastfeeding
• High predischarge bilirubin level
• Cephalhematoma / bruises
• Babies of diabetic mothers
• Family history of severe NNJ in siblings
 Approach
History
• Age of onset
• Previous infant with NNK, kernicterus,neonatal
death,G6pd deficiency
• Mother’s blood group
• Gestation
• Presence of abnormal symptoms: apnea,
difficulty in feeding, feed intolerance,temperature
instability
 Physical examination
• General condition: gestation and weight,sign of
sepsis, hydration status
• Sign of kernictrus: letahrgy, hypotonia, seizure,
opisthotonus, high pitch cry
• Pallor, plethora, cephalhematoma,
subaponeuritic hemorrhage
• Sign of intrauterine infection: petechiae,
hepatosplenomegaly
• Cephalo-caudal progression of severity of
jaundice
 CLINICAL ASSESSMENT OF THE
SEVERITY OF JAUNDICE
• When neonate is jaundiced, the yellow discoloration of skin 1st
appears on:
– face → progress to the trunk → palm of the hand → sole of the feet
– (cephalo-caudal progression)
• Method: blanching the skin of the neonate with digital pressure
exposing the colour of the underlying skin. Difficult in dark skinned
infants.
• Intensity and severity of yellow discoloration is corresponding to
the cephalo-caudal progression.
• Severity of neonatal jaundice is assessed clinically using Kramer’s
chart based on dermal zones of neonatal jaundice, where the levels
of serum bilirubin correlate with the area of skin that is jaundiced.
Cont.
• Measurement of Bilirubin Levels
Newborn
detected with
yellow
discoloration of
skin beyond the
leg, or

Lab
Confirmatory
of TSB

Their clinically
assessed TSB
level approach
phototherapy
range
 Management
Indication to referral to hospital
• Jaundice within 24hrs
• Jandice below umbilis (corresponds to serum
bilirubin 200-250Umol/L)
• Jaundice extending to soles(urgent referral, may
need ET!!!!)
• Family history of signficant hemolytic
disease/kernicterus
• Any unwell infant with jaundice
• Prolong jaundice >14days
- refer infant with conjugated
hyperbilirubinemia urgently to hospital
- Infants with unconjugated hyperbilirubinemia
can be investigated and referred only if the
jaundice does not resolve or a definitive cause
found
 INVESTIGATIONS
Investigation Example
First line • Total serum bilirubin
• Blood group of mother and baby: detects any incompatibility

Second line • Direct coombs test: detect presence of antibody coating on fetal RBC
• Hematocrit: decreased in hemolysis
• Reticulocyte count: increase in hemolysis
• Peripheral blood smear
• G6PD levels in RBC
• Others: sepsis screen, thyroid function test, urine for reducing
substances to rule out crigler najjar, gilbert and other genetic enzyme
defeciencies.
 Investigations
1. Full blood count
– to detect low levels of Hb from haemolysis and infection
2. BUSE
– 80% of jaundice occurs in preterm infants and their fluid electrolyte requirements are
different
3. Blood culture & sensitivity
– to determine causative organism if culture shows +ve for bacterial growth as to start
suitable antibiotic treatment.
4. CRP
– to determine if any inflammatory reactions are present, infection
5. PT/aPTT
– to exclude any coagulation disorders, hemorrhagic disease of the
newborn
6. Group Cross Match
– For emergency blood transfusion
7. Cardiac enzmyes
– to check for ischaemic injury because of birth asphyxia
8. ABG
– to determine SaO2 level and presence of alkalosis or acidosis from birth asphyxia
9. Chest X-ray
– To diagnose respiratory disorders & confirm position of endotracheal tube & umbilical
artery catheter.
 TRANSCUTANEOUS TOTAL SERUM BILIRUBIN
BILIRUBINOMETRY (TcB)
• Is an instruments measuring bilirubin level using • If TcB not available
spectrophotometry. • For babies
• For the babies: • Gestational age <35 weeks
• Gestational age of 35 weeks or more • < 24 hours of age
• >24 hours of age • If bilirubin level >14mg/dL (>250 µmol/L)
• May decrease the number of heel pricks and/or • Preferred once baby is at the relevant treatment
invasive blood tests threshold and for subsequent measurements.
• If not available, measure serum bilirubin
• If TcB level greater than 14mg/dL (>250 µmol/L)
→ measure serum bilirubin
 Treatment
• AVOID SUNLIGHT EXPOSURE DUE TO RISK OF
DEHYDRATION AND SUNBURN
• Phototherapy lights, minimum irradiance of 15
microW/cm2/nm
• Light source 35-50 cm from top surface of the infant
• Expose infant adequately; cover eyes
• Monitor serum bilirubin level as indicated
• Monitor infant’s temperature 4 hourly to avoid chilling
or overheating
• Adequate hydration and good urine output
• Allow parenteral-infant interaction
 Treatment
• Discontinue when serum bilirubin is below
phototherapy level
• Turn off photolights and remove eyepads during
feeding and blood taking
• Visual observation as means of monitoring is not
reliable. Serum bilirubin levels must be checked
• Without hemolytic disease, average increase of
bilirubin (rebound jaundice) <1 mg/dl, can
discharge and no further measurement necessary
 Additional Notes
• Failure of phototherapy
• Do an immediate exchange transfusion if
infant shows signs of acute bilirubin
encephalopathy
• Use total bilirubin level
• Exchange transfusion (ET) indicated if Total
Serum Bilirubin is more or equal 5mg/dl
• IVIG 0.5-1 gm/kg over 2 hours reduces the
need for ET in Rh and ABO hemolytic disease
Measures to Prevent Severe Neonatal
Jaundice
• Frequent breast feeding (8-10 times/ 24hours)
• G6PD status must be known before discharge
• Infants placed under observation during first
24 hours of life if mothers with blood group
‘O’ and sibling with neonatal jaundice
• If phototherapy is discontinued early, monitor
for rebound jaundice and adequate breast
feeding for 1-2 days
 Follow-up
• Infants with serum bilirubin >20mg/dl and
require ET must be followed up for
neurodevelopment outcome
• If discharged <48 hours, follow up by
healthcare professional within 2-3 days of
discharge
• Follow-up for neonatal jaundice
 Exchange tranfusion indication
• Double volume exchange
-blood exchange tranfusion to lower serum
bilirubin level and reduce risk of brain damage
associated with kernicterus
-hyperammonaemia
-to remove bacterial toxins in septicemia
-to correct life threatening electrolystes and
fluid disorders in acute renal failure
• Partial exchange transfusion
-to correct polycyathemia with hyperviscosity
-to correct severe anemia without hypovolemia
 Preparation of infant
• Conset!
• Ensure resuscitation equipment is ready
• Stabilize and maintain temperature, pulse and
respiration
• Obtain peripheral venous access for maintenace
IV fluids
• Proper gentle restraints
• Continue feeding the child, omit only last feed
before ET. If <4hrs from last feed, empty gastric
contents by NG aspiration before ET
 Type of blood
• Rh isommunisation: ABO campatible, RH
negative blood
• Other condition: cross-match with baby and
mothers blood
• In Emergency: O Rh negative
 Exchange Transfusion
• Procedure (perfome under aseptic technique using
gown and mask)
– Volume to be exchange 2x the infant ‘s total blood volume
– Use fresh whole blood <5days old / reconstituted Packed
Red Blood Cells and FFP in aration of 3:1.
– Connect baby to cardiac monitor
– Take baseline investigations and record down on national
Exchange blood transfusion (Apex beat,respiration and
Blood transfusion recorded avery 15 minutes)
– Cannulate umbilical vein to depth not more than 5-7cm in
term infant – for catheter tip to be proximal to portal sinus
– Withdrawal of 5-20ml of newborn’s blood alternating with
infusion of equal volume of donor’s blood
• Pre warm blood to a body temperature usiang a water bath.
• Shake blood gently every 5-10 cycles to prevent settling of RBC
• rate of exchange: 3-4 minutes per cycle
• Syringe should be held vertical during infusion “in” to prevent air
embolism
• Total exchange duration should be 90-120minutes utilisng 30-35 circles
• Begin the exchange with an initial removal of blood, so there always
deficit to avoid cardiac overload
• Routine administration of calcium gluconate is not recommended
• Remove the UVC after the procedure unless a second ET is anticipated
and there was difficulty inserting the UVC
• Continue ET after the procedure
• Repeat ET may be required in 6hrs for infant with high rebound SB
• Feed after 4hrs if patient is well and a repeat ET not required
• If child is anemic (hb <12), give an extra of aliquot volume of blood
(10mls/kg) at the end of tranfusion at the rate of 5mls/kg/hr after ET
• If infant is on any medication., to readminister medication after ET
 Investigation
Pre- exchange (1st volume of blood removed)
• Serum bilirubin
• FBC
• Blood C+S (via periopheal blood, UVC to reduce
contamination)
• HIV, hepatitis B
Post-exchange(Discard initial blood remaining in IVC before
sampling)
• Serum bilirubin
• FBC
• Capillary blood sugar
• Serum electrolystes and calcium
 Post ET management
• Maintain ET
• Monitor vital sign:
Hourly for 406hr and 4hrly subsequently
• Monitor capillary blood sugar:
Hourly for 2 hrs following ET
• Check serum bilirubin : 4-6hrs after ET
 Follow up
• Long term follow up to monitor hearing and
neurodevelopmental assesment
Partial Exchange tranfusion
Exchange Transfusion
Prolonged Jaundice in Newborn
infant
 Visible jaundice (or serum bilirubin >85mol/l that persists
beyond 14days of life in a term infant / 21 days in preterm infant
 Unconjugated hyperbilirubinemia
• Admit infant is unwell. Otherwise follow up
until jaundice resolves.
• Investigation: Thyroid function, urine FEME
and C+S, urine for reducing sugar, FBC,
reticulocyte count, peripheral blood film,
G6PD screening
 Conjugated hyperbilirubinemia
• Conjugated bilirubin > 25Umol/l
• Investigate for biliary atresia and neonatal
hepatitis syndrome
• Other test: LFT, coagulation profile, lipid profile,
Hepatitis B and C virus status, TORCHES, VDRL
test, alpha-1-antitripsin level
• Admit and observe stool color for 3 conservative
days. If pale most probbaly biliary atresia,
consider Urgent referral to Paediactric Surgery
• Other ix: GGT, US of liver
• Billiary atresia: Kasai procedure, perfomed within 2 months
of life.
• Further ix
Metabolic causes
Classical galactosaemia
Citrin deficiency
Tyrosinaemia type 1
Neonatal haemochromatosis
Primary bile acid synthesis disorder
Perixisomal biogenesis disorder
Mitochondrial depletion syndrome
Infective causes- septicaemia, UTI,Herpes Simplex virus
infection, Hep B infeection
Alagillesyndrome
Idiopathic neonatal Hepatitis syndrome
THANK YOU! ☺