Neonatal jaundice (1).pptx Kaumarbhritya

Notes

1. Neonatal jaundice by- Kamakshi sharma bams 3 rd prof.

2. Neonatal jaundice Jaundice is a Yellowish dicolouration of skin and mucous membrane due to excessive accumulation of bilirubin in the blood . Jaundice is an important problem in the first week of life. High Bilirubin levels may be toxic to the developing central nervous system and may cause neurological impairment even in term newborns Nearly 60% of term and 80% preterm newborns become visibly Jaundiced in the first week of life Approximately 5%-10% of them have clinically significant Jaundice requiring use of Phototherapy or other therapeutic options. Yellowish discolouration is first evident on Skin of Face,Nasolabial folds and tip of Nose. It is marked by Physiological Plethora of newborn and can be brought out by blanching the skin so that underlying yellowness of subcutaneous tissue and blood vessels can be visualised. Eyes and Sclera can be best examined by holding the infant against diffuse light and without trying to forcibly open the eyelids. It is essential that all newborns babies must be clinically screened twice a day in a good day light to detect onset and severity of jaundice. 2 .

3. 3

4. 4

5. 5

6. 6

7. 7 In term babies Physiological jaundice appears between 36 and 72 hours of age. Maximum intensity is seen on 4th day. Serum bilirubin does not exceed 15mg/ dl and jaundice disappears by 10 days of life. There are no characteristics clinical features of physiological jaundice and its diagnosis cannot be made by examining the baby at the one point of time. Instead, the diagnosis is made by retrospectively by the time of onset of jaundice, maximal limits of intensity and age of disappearance besides the exclusion of pathologic causes. Among preterm babies Age of onset of physiologic jaundice is similar to term babies. It may manifest earlier but never before 24 hours of age. The maximum intensity of jaundice is reached on 5th or 6th day. Serum bilirubin may go upto 15mg/dl and is may persist upto 14th days.

8. 8

9. 9 CAUSES The age of onset of jaundice gives an clue to possible etiology. Important causes of jaundice in neonates includes – Hemolytic causes Non- hemolytic causes Hemolytic causes • Rh incompatibility • ABO incompatibilty • G6PD deficiency Non- hemolytic causes • Prematurity, polycythemia • Inadequate feeding • Breast milk jaundice • Idiopathic

10. 10 Causes are usually classified based on time of onset of jaundice. APPEARING WITHIN 24 HOURS OF BIRTH • Hemolytic disease of newborn – RH, ABO and minor group incompatibility. • Infection- syphillis, rubella Au antigen-hepatitis, herpes simplex and bacterial infections. • Administration of large amount of certain drugs, such as vitamin K, salicylates, sulfisoxazole etc. to mother. • Hereditary spherocytosis. BETWEEN 24 AND 72 HOURS OF LIFE • Physiological • Sepsis • Birth asphyxia • Polycythemia • Concealed hemorrhages- cephalohematoma, subarachnoid bleed, IVH • Increased enterohepatic circulation • Hypoglycemia • Hyperbilirubinemia of newborn

11. 11 AFTER 72 HOURS (WITHIN FIRST 72 WEEKS) • Septicemia • Neonatal hepatitis • Extrahepatic biliary atresia • Breast milk jaundice • Metabolic disease such as galactocemia, tyrosinemia, cystic fibrosis, intestinal obstruction.

12. 12 BREASTFEEDING JAUNDICE Jaundice in breastfeed babies usually appears between 24 and 72 hrs of age, peaks by 5-15 days of life and disappears by third week of life. One third of all breast feed babies are detected to have mild clinical jaundice in the 3rd week of life in a few babies. The increased frequency of jaundice in breastfeed babies is not related to characteristics of breast milk but rather to inadequate breastfeeding. Ensuring optimum breast feeding woulh help decrease this type of jaundice. BREAST MILK JAUNDICE Approximately 2-4% of exclusively breastfed term babies have jaundice in excess of 10mg/dl beyond 3rd 4th weeks of life. It occurs as a result of sustances such as 3-alpha, 20-alpha pregnanediol, and free fatty acids in mothers milk which inhibits conjugation of bilirubin. It resolves on its own.

13. 13

14. 14

15. 15 • The clinical jaundice manifest as described by kramer scale , dermal staining of bilirubin may be as a clinical guide to level of jaundice. • Dermal staining in newborn progresses in a cephalocaudal direction. • The newborn should be examined in good daylight. • The skin of forehead, chest, abdomen, thighs , legs, palms, and soles should be blanched with digital pressure and the underlying colour of skin and sub cutaneous tissue should be noted.

16. 16 Other examinations are- • Gestational age, activity and general condition of infant • Whether umbilicus is septic • Whether any evidence of hemorrhages, petechiae etc. • Any congenital malformation • Any neurologic finding • Colour of urine and stool • pallor Serum levels of total bilirubin are approximately- ZONE 1- 4-6mg/dl ZONE- 8-10mg/dl ZONE – 12-14mg/dl ZONE-15-18mg/dl ZONE- 15-20mg/dl Yellow staining of palms and soles is a danger sign and requires urgent serum bilirubin estimation and further management.

17. LABORATORY INVESTIGATIONS Most cases of jaundice in newborn are due to physiological causes and do not need any investigation. Investigations are indicated in the following high risk situations : History of severe jaundice or exchange blood transfusion or kernicterus in a previous sibling. Mother O group or RH negative Onset of jaundice within 24 hrs or after 72 hrs of age. Trunk significantly or distinctly yellowed stained. Therefore, lab investigations include- serum bilirubin, both direct and indirect Conjugated bilirubin less than 2mg/dl% or more than 20% of total should be considered abnormal. 17

18. Hemoglobin / peripheral smear Reticulocyte count Blood culture Liver function tests G6PD enzyme studies Coomb’s test of mother as well as baby

19. APPROACH TO AN INFANT WITH JAUNDICE Perform visual assessment of jaundice: every 12 hrs during initial 3 to 5 days of life. Visual assessment can be supplemented with transcutaneous bilirubinometry (TCB), if available. 19

20. Serious jaundice Presence of visible jaundice in first 24 hrs Yellow palm and soles Signs of acute bilirubin encephalopathy or kernicterus , hypertonic , abnormal posturing such as arching, convulsions, fever, high-pitched cry. Measure serum bilirubin if Jaundice in 1 st 24 hrs Beyond 24 hrs- if on visual assessment or by transcutaneous bilirubinometry, total bilirubin is likely to br more than 12 -14 mg/dl or approaching phototherapy range or beyond If you are unsure about visual assessment 20

21. TREATMENT Phototherapy and exchange transfusion are the 2 major effective therapeutic modalities available today additional options include pharmacotherapy in the form of phenobarbital, agar-agar, albumin infusion, charcoal etc. PHOTOTHERAPY First introduced by Kramer, phototherapy has emerged as the most widely used tool for treating unconjugated pathologic hyperbilirubinemia. 21 Birth weight (g) Serum bilirubin at which phototherapy indicated(mg/dl) 2,500 15 2000-2,500 12 1,500-2000 10 1000-1,500 7 <1000 5

22. 22

23. MODE OF ACTION in order to understand its mode of action, it should be remembered that bilirubin absorbs the blue-green light maximally 460-490nm. With light source of this range, most of it(80%) undergoes photoisomerization to bilirubin of better soluble form. A small portion gets oxidized to biliverdin. These are excreted in bile and to a lesser extent in urine. A common observation during phototherapy is the bleaching of exposed areas. The areas of skin that remains covered continue to have yellow touch. 23

24. TECHNIQUE- It is now generally opined that blue light is superior to white light. Most neonatal units employ standard length tube lights (STL) phototherapy. Alternatively, compact fluorescent lamp (CFL) and LED phototherapy units now available in india may be employed. It is claimed that these are superior to conventional (STL) units on account of smaller size, focused area, lower scatter, and higher irradiance. Such phototherapy unit delivers about 200 foot candles of light to the infant. The only problem with blue light is that it intereferes with reasonable observations of baby . Alternatively, white day-light lamp/ tubes are reasonably effective and may be employed. LENGTH OF PHOTOTHERAPY Just 24-48 hrs exposure is generally long enough to bring down serum bilirubin level to safe limits. Skin colour is not a reliable criteria for stopping or continuing phototherapy. The yellow colour of skin disappears or regress much earlier than the return of serum bilirubin level to near normal. 24

25. It is therefore, desirable that serum bilirubin estimation is done at intervals of 12hrs. Terminaton of phototherapy is indicated at serum bilirubin less than 11g/dl on two consecutive sitings 24 hrs apart. PREACAUTIONS During exposure to phototherapy ,infants eyes should be protected with something like a mask, In case of male neonate the external genitalia too need to be covered to prevent gonadal insult. CONTRAINDICATIONS Congenital erythropoietic porphyria SIDE EFFECTS Immediate - loose motions, dehydration , fevr, hypocalcemia, electric shock, skin rashes. Delayed- retinal damage, late anemia, skin malignancy 25

26. 26

27. EXCHANGE TRANSFUSION Double volume exchange transfusion (DVET) should be performed if the TSB levels , Reach tomage specific cut-off for exchange tramsfusion or the infant shows signs of bilirubin encephalopathy irrespective of TSB levels. Indications of DVET at birth in infants with Rh isoimmunization include – Cord bilirubin is 5mg/dl or more Cord hb is 10g/dl or less At birth if baby shows signs of hydrops or cardiac decomposition in presence of low PCV (<3.5%) PREVENTION Antenatal investigation should include maternal blood grouping . Rh positive baby born to an Rh negative mother is at higher risk for hyperbilirubinemia and requires greater monitoring Anti-D injection after first obstetrical event ensures decreased risk of sensitization in future pregnancies. Ensuring adequate breast feeding. 27

28. 28

29. Thank you