Clinical Approach to jaundice in newborns

The presentation covers on approach to jaundice in newborns..

1. A p p r o a c h t o a j a u n d i c e d n e o n a t e

2. BILIRUBIN B i l irubin i s t h e d e g e n e r a tion p r o d u ct o f h aemprotein s

3. N E O N A T A L J A U N D I C E Nearly 60% of term newborn becomes visibly jaundiced in the first week of life . In most cases, it is benign and no intervention is required .

4. P h y s i o l o g i c a l v e r s u s p a t h o l o g i c a l j a u n d i c e P h y s i o l o g i c a l -d u e t o p h y s i o l o g i c a l i m m a t u r i t y o f n e o n a t e s t o h a n d l e i n c r e a s e d b i l i r u b i n p r o d u c t i o n . S t a r t s i n 2 4 - 7 2 h o u r s o f a g e P e a k s b y 3 d a y s o f l i f e a n d t h e n f a l l s P a t h o l o g i c a l - T S B e x c e e d s : 5 m g / d l on 1 s t d a y 10 m g / d l o n s e c o n d d a y 15 m g / d l t h e r e a f t e r

5. Presence o f f o l l o w i n g s i g n s i n d i c a t e p a t h o l o g i c a l j a u n d i c e : . C l i n i c a l jaundice d e t e c t e d before 2 4 h r s . R i s e i n s e r u m b i l i r u b i n > 5 m g / d l / d a y . . S e r u m b i l i r u b i n > 1 5 m g / d l . C l i n i c a l j a u n d i c e p e r s i s t i n g b e y o n d 1 4 d a y s o f l i f e . C l a y o r w h i t e c o l o u r e d s t o o l s a n d o r d a r k u r i n e s t a i n i n g t h e cloth y e l l o w . Direct b i l i r u b i n > 2 m g / d l a t a n y t i m e

6. BREASTFEED I N G J A U N D I C E I n e x c l u s i v e l y b r e a s t f e d i n f a n t s A p p e a r s i n 2 4 - 7 2 h r s o f l i f e , p e a k s b y 5 - 1 5 d a y s a n d d i s a p p e a r s b y 3 r d w e e k . 1 / 3 r d o f a l l breastfed b a b i e s h a v e m i l d c l i n i c a l j a u n d i c e i n 3 r d w e e k N o t d u e t o c h a r a c t e r i s t i c s o f breast m i l k b u t d u e t o i n a d e quate b r e a s t fe e d i n g .

7. B R E A S T M I L K J A U N D I C E 2 - 4 % o f exclusively breastfed t e r m b a b i e s h a v e j a u n d i c e i n e x c e s s o f 1 m g / d l b e y o n d 3 r d - 4 t h weeks o f l i f e . M o t h e r s advised t o c o n t inue b r e a s t feeding a t f r e q u e n t i n t e r v a l s .

8. C l i n i c a l E s t i m a t i o n D e r m a l staining o f b i l i r u b i n P r o g r e s s e s i n c e p h a l o c a u d a l d i r e c tion . E x a m i n e d i n good d a y l i g h t . S k i n o f forehead , c h e s t , a b d o m e n , t h i g h s , l e g s , p a l m s , s o l e s i s b l a n c h e d w i t h d i g i t a l p r e s s u r e , c o l o r n o t e d . Y e l l o w s t a i n i n g o f p a l m s a n d s o l e s i s a d a n g e r s i g n . R e q u i re s s e r u m b i l i r u b i n e stimation.

9. 1 : . 4 - 6 m g / d l 2 : . 6 - 8 m g / d l 3 : . 8 - 1 2 m g / d l 4 : . 1 2 - 1 4 m g / d l 5 : . > 1 5 m g / d l

10. Base d o n t i m e o f o n s e t A p p e a r i n g w i t h i n 2 4 h r s o f a g e : H a e m o l y t i c d i s e a s e : R h , A B O a n d m i n o r g r o u p i n c o m p a tibility I n f e ction s : i n t r a u t e r i n e v i r a l , b a c t e r i a l ; m a l a r i a A p p e a r i n g i n 2 4 - 7 2 h r s o f l i f e : P h y s iological . Sepsis . P o l y c y themia . C o n c e a l e d hemorrhages : c e p h a l o h e m a t o m a

11. A p p e a r i n g a f t e r 7 2 h r s : . S e p s i s . N e o n a t a l h e p a t i t i s . E x t r a h e p a t i c b i l i a r y a t r e s i a . B r e a s t m i l k j a u n d i c e . M e t a b o l i c d i s o r d e r s

12. A p p r o a c h t o a jaundiced n e o n a t e A l l neonates v i s u a l l y i n s p e c t e d f o r j a u n d i c e e v e r y 1 2 h r s i n i n i t i a l 3 - 5 d a y s . T r a n s c u taneous b i l i r u b i n ( T c B ) u s e d a s a n a i d i n initial s c r e ening .

13. M a n a g e m e n t

14. I n v e s t i g a t i o n s F i r s t l i n e : T o t a l s e r u m b i l i r u b i n . B l o o d g r o u p s o f m o t h e r a n d b a b y : d e t e c t s i n c o m p a tibility . P e r i p h e r a l s m e a r : e v i d e n c e o f h a e m o l y s i s . S e c o n d l i n e : . D i r e c t coombs t e s t : presence o f antibody coating o n f e t a l R B C . H e m a t o c r i t : d e c r e a s e d i n haemolysis . R e t i c u l o cyte c o u n t : increased i n h a e m olysis . G 6 P D l e v e l s

15. P h y s i o logical J a u n d i c e B r e a s t f e e d f r e q u e n t l y a n d e x c l usively . B r i n g ba b y t o hospital i n c a s e of d a n g e r s i g n s .

16. P r o l o n g e d jaundice I f b a b y h a s s i g n i f icant j a u n d i c e , investigations t o r u l e o u t : . c h o l e s t a s i s . o n g o i n g haemolysis . h y p o t h y r o i d i s m . u r i n a r y tract i n f ection

17. Phototherapy M a i n s t a y o f t r e a tment i n Neonatal h y p e r b i l irubinemia . C o n v e r t s u n c o n j u g a t e d b i l i r u b i n i n t o s o l u b l e i s o m e r s t h a t i s e x c r e t e d i n u r i n e a n d f a e c e s . Bilirubin s h o u l d b e present i n s k i n , s o n o r o l e i n prophylaxis.

18. A c t s b y several w a y s : . configuration a l isomerization . s t r u c t u r a l isomerization . p h o t o o x i d a t i o n . C F L p h o t o t h e r a p y : m o s t c o m m o n l y u s e d . . I r r a d i a n c e : m i n i m u m 3 m i c r o W / c m / n m . Wavelength : 4 6 - 4 9 n m .

19. Administration o f p h o t o t h erapy R o o m temperature o f 2 5 - 2 8 ℃ . R e m o v e a l l c l o t h e s o f b a b y e x c e p t d i a p e r . Cover e y e s w i t h eyecatch. P l a c e n a k e d b a b y u n d e r t h e l i g h t s i n a c o t i f w e i g h t > 2 k g o r i n a n i n c u b a t o r i f w e i g h t < 2 k g . Keep d i s t a nce b t w baby and l i g h t 3 - 4 5 c m .

20. E n s u r e o p t i m u m breast f e e d i n g . M o n i t o r i n g t e m p e rature e v e r y 2 - 4 h r s a n d T S B l e v e l every 1 2 - 2 4 h r s . S t o p p h o t o t herapy o n c e t w o T S B values 1 2 h r a p a r t f a l l s b e l o w current a g e specific c u t o f f s . L o o k f o r a n y r e b o u n d r i s e .

21. E x c h a n g e transfusion Double v o l u m e e x c h a n g e t r a n s f u s i o n ( D V E T ) T S B r e a c h a g e s p e c i f i c c u t o f f f o r t r a n s f u s i o n B i l i r u b i n e n c e p h a l o p a t h y

22. I n d i c a t i o n s f o r D V E T a t b i r t h C o r d b i l i r u b i n 5 m g / d l o r m o r e C o r d H b 1 g / d l o r l e s s .

23. P r e v e n t i o n A n t e n a t a l investigation E n s u r i n g a d e q uate b r e a st f e e d i n g P a r e n t e d u c a t i o n H i g h r i s k b a b i e s b e f o l l o w e d u p .