Neonatal Jaundice (N)

Question 1

What are the causes <24hours?

Answer 1

1. Haemolytic disorder e.g. Rh incompatibility, ABO incompatibility, G6PD, spherocytosis, PKD
   - ABO incompatibility is more common but less severe jaundice, Hb is normal or slightly reduced, no hepatosplenomegaly, Coomb’s test performed. Jaundice peaks at 12-72hrs
2. Congenital infection - Conjugated Br. Other abnormal signs e.g. growth restriction, hepatosplenomegaly, thrombocytopaenia. CMV most common.

Question 2

What are causes in infants 24 hours-2weeks?

Answer 2

1. Physiological 🡪 no cause, adapting to life outside. Only use this if everything else excluded.
2. Breast milk jaundice 🡪 common, unconjugated
3. Infection e.g. UTI 🡪 jaundice due to poor fluid intake, haemolysis, reduced liver function, increased enterohepatic cycling
4. Haemolysis e.g. G6PD, ABO
5. Bruising
6. Polycythaemia (Hct >0.65)
7. C-J syndrome 🡪 glucuronyl transferase absent, unconjugated Br
8. Dehydration 🡪 >10% weight loss from birth weight, poor feeding

Question 3

What are causes in infants <2 weeks?

Answer 3

Unconjugated 🡪 physiological, breast milk, infection, congenital hypothyroidism, haemolytic anaemia, high GI obstruction e.g. pyloric stenosis

Conjugated 🡪 bile duct obstruction, neonatal hepatitis, biliary atresia
Dark urine, pale stools, hepatomegaly

Question 4

What are the risk factors?

Answer 4

1. Previous sibling with jaundice
2. Visible jaundice in 24hrs of life
3. Breast fed babies (in 1st week of life and prolonged jaundice >14 days vs formula fed)
4. Gestational age <38 weeks

Others 🡪 Bruising, cephalohaematoma, males, maternal age >25, maternal DM, dehydration, dark skin tone

Question 5

What investigations are carried out?

Answer 5

If <25 weeks or <24 hrs old 🡪 serum Br

If >35 weeks or >24 hrs old 🡪 transcutaneous Br (if >250umol/L measure serum Br)

If >37 weeks or jaundice >14 days OR If <37 weeks and jaundice >21 days 🡪 split Br (if conjugated fraction>20% refer to specialist paediatric liver centre)

Serum Br in everyone to confirm diagnosis

• Blood PCV
• Blood group (mother and baby)
• Coomb’s test
• If indicated 🡪 FBC, blood film, G6PD level, blood/ urine/ CSF culture, LFTs

rate of change is linear until a plateau, take serial Br measurements and plot on chart and anticipate treatment if threshold levels reached

*preterm are more susceptible to damage from Br so threshold to intervene is low

**if infant has severe hypoxia, hypothermia, serious illness they are more susceptible to Br damage. Avoid drugs that displace Br from albumin in newborns e.g. sulphonamides

Question 6

What is the management?

Answer 6

*Varies depending on age at onset, gestational age, Br level and rate of rise, overall clinical condition

Information
Recognise jaundice in 24hrs of life, seek urgent advice
Adequate hydration
Check nappies for dark urine, pale stools
Continue breastfeeding every 3hrs, wake baby for feeds, do not supplement with water/ formula
Neonatal jaundice is common, transient and harmless
Physiological is harmless, resolves in 2 weeks
Breast milk jaundice is benign and self limiting
Support groups 🡪 NICE neonatal jaundice info sheet, Bliss special care baby charity, the breastfeeding network

Assessment
Rh status, ABO mother, gestational age at birth
Age of onset of jaundice
Feeding hx of baby, dehydration
Number of wet or dry nappies in day
Illness, lethargy, fever, vomiting, weightloss, irritability
FHx – G6PD siblings needing phototherapy/ exchange transfusion for jaundice

Emergency admission
999 ambulance if jaundice + features of encephalopathy

• Urgent admission to paediatric unit and seen in 2hrs
  Jaundice <24hrs, measure serum Br urgently (<2hrs), continue to measure every 6hrs until stable/ falling and below treatment threshold level
• Urgent admission to be seen in 6hrs
  Measure Br <6hrs if jaundice appear at >7 days life, unwell neonate, gestational age <35 weeks
  Prolonged jaundice = >37 weeks +2 weeks jaundice OR <37 weeks +3 weeks jaundice
  Poor feeding, pale stools, dark urine

Management after admission to secondary care
Correct dehydration
No treatment 🡪 physiological or breast milk jaundice. Br below threshold
Phototherapy 🡪 light 450nm blue-green converts uBr to products easily excreted in stool or urine. Can cause bronze discoloration of skin.
Exchange transfusion 🡪 signs of encephalopathy, kernicterus, unresponsive to phototherapy. Admit to PICU, need intensified phototherapy during and after. Serum Br measured 2hr after stopping. Blood removed from umbilical vein/ art line in small aliquots and replaced with donor blood
Treat infection, surgical management of biliary atresia
IVIG 🡪 Rh disease, ABO incompatibility unresponsive to intensive phtotherapy IVIG reduces need for exchange transfusion

Question 7

What is the major complication of neonatal jaundice?

Answer 7

Kernicteru
lethargy, poor feeding, severe irritability, increased muscle tone (arched back), seizures, coma

Infants that survive may have choreoathetoid cerebral palsy, learning difficulties, sensorineural deafness