Neonatal jaundice P149 Flashcards
A neonate refers to……
Jaundice is a physical………
•Approximately 80% of newborns will be jaundiced in the first week of life, which is physiological. It is mild and baby is healthy
True or False?
A neonate refers to a 0 to 28 day old baby
•Jaundice is a physical exam finding referring to yellow discoloration of the skin, caused by bilirubin deposition
True— •Approximately 80% of newborns will be jaundiced in the first week of life, which is physiological. It is mild and baby is healthy
PATHOPHYSIOLOGY OF BILIRUBIN METABOLISM AND JAUNDICE
PATHOPHYSIOLOGY OF BILIRUBIN METABOLISM AND JAUNDICE
BILIRUBIN METABOLISM
•Hemoglobin is broken down to heme and globin
•Heme further breaks down to biliverdin and then, to bilirubin.
•Bilirubin binds to albumin in the bloodstream and delivered to the liver
•After carrier-mediated uptake, bilirubin is conjugated (with one or more molecules of glucoronic acid) by hepatic Transferase UGT1A1
•Conjugated bilirubin is excreted in the bile
•It is subsequently deconjugated by gut bacteria and degraded to urobilinogens that are primarily fecally eliminated
•Jaundice occurs when bilirubin production exceeds
•Jaundice occurs when bilirubin production exceeds
- hepatic uptake
- conjugation
- and/or excretion
•That is, hyperbilirubinemia
•There are two types of hyperbilirubinemia
1.Unconjugated hyperbilirubinemia
. Results from excess bilirubin production, diminished liver uptake, diminished conjugation
2.Conjugated hyperbilirubinemia
Jaundice in the neonate is likely to be
Jaundice in the neonate is likely to be pathophysiological if;
1.It is present within the first day of life
2.Conjugated/direct bilirubin is more than 40micromol/L
3.Total bilirubin >170 micromol/L in preterm, >260 micromol/L in term
4.Neonate is significantly jaundiced beyond 14days or has jaundice with fever 🤒
Causes of Neonatal Jaundice
CAUSES OF NEONATAL JAUNDICE
Causes
y Physiological
y Haemolysis - Rhesus, ABO incompatibility, G6PD deficiency
y Blood extravasation - cephalhaematoma, subgaleal haematoma
y Sepsis
y Congenital infections
y Liver disease
y Metabolic disorders - galactosemia, hypothyroidism
y Enhanced extra hepatic circulation - GIT obstruction, inadequate
feeding
y Congenital defects of bilirubin metabolism
y Breast milk related jaundice
A.Physiologic Jaundice
- High hematocrit + fetal RBC with shorter lifespan
- decreased metabolism of unconjugated bilirubin due to inactivity of UGT1A1 in-utero
- decreased excretion of bilirubin as neonate are working to feed and work towards a normal stool pattern
- Physiologic Jaundice should have resolved within 10 days or 2 weeks.
B. Pathogical Jaundice
1.Severe Hemolysis
-ABO/RH incompatibility
-G6PD deficiency
-Hereditary Spherocytosis
-Sepsis
-Polycethemia
2.Blood Extravasation
-Cephal Hematoma
-GIT obstruction
-Inadequate breastfeeding
-Breast milk related jaundice
- Congenital defects of bilirubin metabolism
For instance defective bilirubin conjugation;
• crigler-Najjar syndrome
• Gilbert syndrome
• Dubin Johnson syndrome
• Rotor syndrome - Liver disease
- Hypothyroidism
- Galactosaemia
- Congenital Infections
- Biliary Atresia
Risk Factors Of Jaundice
RISK FACTORS
•Race
•Geography
•Genetics and familial risk
•Nutrition
•Maternal factors
•Birth weight and Gestational age
•Congenital infections
COMPLICATIONS OF HYPERBILIRUBINEMIA
COMPLICATIONS OF HYPERBILIRUBINEMIA
•Increased levels of bilirubin over time result in Bilirubin-induced Neurologic Dysfunction (BIND) – bilirubin crosses blood brain barrier and binds to brain tissue
•The acute manifestations of BIND (Acute bilirubin encephalopathy) includes
-Lethargy. - Hypotonia. - poor suck
which progresses to
-Irritability. - high-pitched cry. - hypertonia. - fever. - seizures
•chronic bilirubin encephalopathy (Kernictus)
- Handicapped. - deafness. - cerebral palsy. - mental retardation
- Motor incordination
HISTORY AND EXAMINATION
HISTORY AND EXAMINATION 🧐
History
Focus on newborn’s
-Feeding
-Voiding
-Stooling
-Mental status
-Family history of RBC disorders (eg G6PD deficiency)
-Past blood transfusion
PHYSICAL EXAMINATION
•Vital signs including weight of baby
•General appearance – well looking, vigorous
•Skin and sclera examined for jaundice
•Head examined for cephalhematomatoma
•Abdomen examined for organomegally
•Neurologic exam
-Suck
-Tone
Signs and Symptoms of Neonatal jaundice
Signs
-Jaundice
-Yellow pigment +/- yellow soles of feet
-Pale stools (biliary atresia likely)
Symptoms
-Yellow eyes
-Yellow skin, hands and feet
-Pale stools (biliary atresia likely)
Investigations
INVESTIGATIONS
•Total and direct serum bilirubin Concentration
Early onset (within Ist 24hrs of birth
-Blood group, rhesus group of both mother and infant
-Direct and indirect coombs test, full blood count, G6PD
-Blood film
-Blood, urine, spinal fluid culture
Prolonged Jaundice (after 14 days)
-Liver function test
-Thyroid function test
-Urine R/E and C/S
-Hepatitis B screening
-Abdominal ultrasound scan (exclude biliary atresia)
TREATMENT
TREATMENT
-To prevent Kernicterus (bilirubin encephalopathy)
-To detect and treat underlying cause
Non-Pharmacological treatment
1.Phototherapy and breastfeeding
Phototherapy is started if
-Jaundice is visible on day 1
-Jaundice involves palms and soles of feet
-Jaundice in prematurity
-Unconjugated bilirubin >170 micromol/L in preterm, >260 micromol/L in term neonate
In Phototherapy blue fluorescent tube lights are preferred
•Baby’s eyes are covered
•Total serum bilirubin should be remeasured 4-12 hr interval
•Phototherapy continued until Unconjugated bilirubin levels are below the phototherapy threshold
•Breastfeeding is continued
•Adequate fluid intake
•Prevent hypothermia and hyperthermia
•Discharge if bilirubin levels are below the phototherapy threshold + improved feeding
- Exchange Transfusion
Pharmacological treatment
•Remove or treat Underlying cause
•Correct blood glucose if low
•Treat any associated anaemia if due to Hemolysis
•Treat liver failure as appropriate
What are the different types of newborn jaundice?
What are the different types of newborn jaundice?
There are a few different types of jaundice in newborns.
Physiological jaundice
The most common type of jaundice in newborns is physiological jaundice. This type of jaundice is normal. Physiological jaundice develops in most newborns by their second or third day of life. After your baby’s liver develops, it will start to get rid of excess bilirubin. Physiological jaundice usually isn’t serious and goes away on its own within two weeks.
Breastfeeding jaundice
Jaundice is more common in breastfed babies than formula-fed babies. Breastfeeding jaundice frequently occurs during your baby’s first week of life. It happens when your baby doesn’t get enough breast milk. It can occur due to nursing difficulties or because your milk hasn’t come in yet. Breastfeeding jaundice may take longer to go away.
Breast milk jaundice
Breast milk jaundice is different than breastfeeding jaundice. Substances in your breast milk can affect how your baby’s liver breaks down bilirubin. This can cause a bilirubin buildup. Breast milk jaundice may appear after your baby’s first week of life and may take a month or more to disappear.
Other types of jaundice can occur if your baby has an unrelated medication condition.
Referral Criteria
Referral Criteria
Refer immediately, all babies who develop jaundice within 24 hours of life or who have prolonged jaundice to a paediatrician.
Refer all patients requiring exchange transfusion to an appropriate facility.
