Common Neonatal Jaundice Flashcards
What is neonatal jaundice?
accumulation of excess bilirubin in the blood serum
How is bilirubin formed?
It is a breakdown product of haemoglobin
What does unconjugated bilirubin do?
It is highly lipid soluble and it will cross blood brain barrier
What can be developed from high levels of bilirubin in baby’s blood?
Kernicterus ( seizures and brain damage )
What is the result of unconjugated hyperbilirubinemia ?
- It would increase bilirubin production
- It would decrease bilirubin clearance
- It would increase enterohepatic circulation
When would it unconjugated hyperbilirubinemia occur.?
It would occur within the first 24 hours and the rise of bilirubin level more than 0.2mg/dl per hour or 5mg/dl per day
What are the signs and symptoms of Kernicterus in baby?
Lethargic, poor feeding, abnormal tone, and posturing, high pitch cry & irritability
When does physiologic jaundice occur?
It occurs between > 24-36 hours
It never occur in the first 24 hours
It usually occur on days 2-4, peaks between 4 to 5 days and resolve in 2 weeks
What is the rate of rise in physiologic jaundice?
<85mmol/L
What is the immature hepatic uptake & conjugation process?
It requires the liver enzyme glucuronyl transferase to convert unconjugated bilirubin ( indirect bilirubin ) into water-soluble conjugated bilirubin ( direct bilrubin ) - excrete in urine and stool
What is haemolytic jaundice?
Hemolytic jaundice occurs as a result of hemolysis, or an accelerated breakdown of red blood cells, leading to an increase in production of bilirubin.
What are the different kinds of haemolytic jaundice?
- G6PD deficiency
- ABO / Rh incompatibility
- Drug-induced
- Cephalohematoma ( Pressure on the fetal head ruptures small blood vessels when the head is compressed against the maternal pelvis during labor or pressure from forceps or a vacuum extractor used to assist the birth
- Polycythaemia ( is a type of blood cancer. It causes your bone marrow to make too many red blood cells. )
What is physiologic jaundice?
A newborn’s immature liver often can’t remove bilirubin quickly enough, causing an excess of bilirubin. Jaundice due to these normal newborn conditions is called physiologic jaundice
What other jaundices are there?
- Jaundice of prematurity
- Infection
Prolonged rupture of membrane
UTI
Sepsis - Metabolic disorder ( maternal hyperthyroidism , gestational diabetes )
- Breast milk jaundice ( progesterone from milk decreases activity of liver enzymes in the first few days of breastfeeding )
How do we assess jaundice?
- Cephalocaudal ( Face to Downwards )
- Should be done in natural light
- Assess severity of jaundice
- Risk factor assessment
- Poor feeding / dehydration
- Breast feeding, neonatal jaundice and kernicterus
- ABO & Rh typing and maternal serum screen
- Transcutaneous bilirubin ( TcB ) measurement
What is TCB measurement
The meter measures the yellowness of the subcutaneous tissue of the infant by measuring the difference in optical density of two different wavelengths of light through the skin.
TCB measurement is applicable to which age?
- Well neonate, stable vital signs
- Gestational age > 34 weeks, at least 24 hours of life, up to 14 days of life
If not, they will have to do serum bilirubin
When Serum bilirubin level shoud be done ?
When TcB is at or above indicated level below ( umol/L) 0-24 hours : not applicable as neotate must at least be 24 hours 25-36 hours : 140 36-48 hours : 160 49-72 hours : 180 73 - 120 hours : 200 121 hours - 7 days : 220 8 - 14 days : 240
Some other tests to be done?
- FBC, retic count and direct Coomb’s
Retic count : A reticulocyte count is a blood test that measures how fast red blood cells called reticulocytes are made by the bone marrow and released into the blood.
Coomb’s : A Coombs test, also known as antiglobulin test is either of two blood tests used in immunohematology. - Urea /Electrolytes /Creatinine : to assist therapy for dehydration
- Albumin : SB for albumin ratio
Phototherapy
- It involves the exposure of as much as the baby’s skin as possible
- to blue fluorescent lights, which emits wavelengths in the 430-490nm
- Decreases the bilirubin level by enhancing the conversion of bilirubin in the exposable skin to a more easily excretable form
- Bound to albumin, transported to the liver and excreted into bile
- Increasing the amount of skin exposure to blue lights can enhance bilirubin excretion
What to observe during phototherapy?
- Ensure adequate hydration, at least more than 6 wet diapers
- Observe urine and stool nature & colour
- Check skin integrity
What is the mechanism of excretion of bilirubin?
Excessive breakdown of RBC
Fetal HB : 18-20 g/dl
Life span : 90 days
->
Increased unconjugated bilirubin
->
Immature liver produce sufficient enzyme glucuronyl
transferase for bilirubin conjugation
->
Jaundice ( hyperbilirubinemia ) - unconjugated bilirubin
->
Phototherapy
->
Convert to water-soluble bilirubin and excrete via urine and stool
Single blue phototherapy
- The exposure of one plane of the body’s surface ( e.g. either the baby’s front or back ) to phototherapy light
- Regularly turning the baby helps to maximise the exposure of all surfaces ( turning 2-3 hourly )
- Keep baby warm using heat shield, check 4 hourly temperature, heart rate and respiration rate
- Use eye covers to prevent damage to baby’s eyes, remove during feeding
Double blue phototherapy
The simultaneous exposure of two body surface planes to two separate set of blue lights i.e both front and back
- Recommended if the SB level above double blue phototherapy criteria or if the rate of rise of SB is >5umol/L/hr
What are the side effects of phototherapy?
- Increase insensible water loss ; Temperature instability
- Rashes ; Diarrhoea ; Retinal damage
If double blue phototherapy doesn’t work out, exchange would be used.
Principles of exchange transfusion
An exchange transfusion requires that the person’s blood be removed and replaced.
What are the risk factors for phototherapy?
Low risk factors : physiological jaundice
High risk factors : pre-term, haemolytic jaundice, sepsis, dehydration
What is the management of NNJ?
Feeding
- feeding can be continued ; nil by mouth if the baby needs exchange transfusion
- increase feeds by at least 10% over the usual expected intake
- continue breastfeeding
if not near, or at exchange transfusion level, the baby can be taken off the lights for up to 30 mins to breastfeed
- Once the “off phototherapy” level has been reached and the baby has completed at least 24 hours of phototherapy
What is parental and caretaker education?
- Follow up advice for babies discharged before age 48 hours
- Give thorough breastfeeding advice
- Teach mothers and caregivers the signs of dehydration
What are the signs and symptoms of an unwell baby?
- Medical cause : infection ( URTI, GE, UTI, conjunctivitis, otitis media, meningitis )
- Surgical cause : HI, trauma, intussusception, IO, pyloric stenosis, hernia
- Significant positive history or physical finding that suggest physical illness ( Poor feeding, decreased feeding, vomiting, fever )
- Any features suggestive of NAI or injury
- Abnormal FBC, UFEME, AXR
- Parental anxiety and inability to cope or poor parent-craft
