Neonatal jaundice

onset,classification and management at health post level

1. Neonatal Jaundice Dr Shambhavi Sharma

2. Jaundice comes from the French word jaune, which means yellow. When it is said that a baby is jaundiced, it simply means that the color of his skin appears yellow. It is caused by the accumulation of bilirubin in the skin due to overall increase in total bilirubin in the blood. 2 What does the word "jaundice "mean?

3. Visible form of bilirubinemia Adult sclera >2mg / dl Newborn skin >5 mg / dl. In neonates, evaluation of sclera is difficult because of physiological photophobia . Occurs in 60% of term and 80% of preterm neonates will have jaundice. However, significant jaundice occurs in 6.1 % of term babies that requires treatment. 3

4. Jaundice progressess in the cephalocaudal direction as it increases in intensity. Assessment of jaundice should be done in natural light. The finger is pressed on the baby’s skin, preferably over a bony part, till it blanches The underlying skin is noted for the yellow color Clinical Assessment of Jaundice

5. Assessment of Jaundice

6. Area of body Range of Bilirubin 1. Face 5 mg/dl 2. Upper trunk 10 mg/dl 3. Lower trunk & thighs 12 mg/dl 4. Arms & lower legs 15 mg/dl 5. Palms & soles >15 mg/dl Clinical criteria to assess jaundice

7. Transcutaneous bilirubin: Transcutaneous bilirubinometer: Non invasive

8. Two types of neonatal jaundice are: Physiological jaundice Pathological jaundice Types of neonatal jaundice

9. First appears between 24-72 hours of age Maximum intensity seen on 4-5th day in term and 7th day in preterm neonates Does not exceed 15 mg/ dl Clinically undetectable after 14 days. No treatment is required but baby should be observed closely for signs of worsening jaundice. Physiological jaundice

10. Clinical jaundice detected before 24 hours of age Rise in serum bilirubin by more than 5 mg/ dl/ day Total serum bilirubin more than 15 mg/ dl Direct bilirubin>2 mg/ dl at any time Clinical jaundice persisting beyond 14 days of life. Clay/white colored stool and/or dark urine staining the clothes yellow Pathological jaundice:

11. A simple pneumonic for risk factors is JAUNDICE J - Jaundice within first 24 hrs of life A - A sibling who was jaundiced as neonate U - Unrecognized hemolysis N – Non-optimal sucking/nursing D - Deficiency of G6PD I - Infection C – Cephalhematoma /bruising E - East Asian/North Indian Risk factors for jaundice

12. Kernicterus or Bilirubin encephalopathy: It is a neurologic syndrome resulting from the deposition of unconjugated bilirubin in the basal ganglia and brainstem nuclei. Dangers of hyperbilirubinemia

13. Kernicterus is identified by lethargy and poor feeding, poor or absent Moro's reflex, opisthotonus or convulsions . Perinatal distress factors such as hypoxia, hypothermia,hypoglycemia,acidosis,birth injury and septicemia increases the risk of BIND.

14. All newborns should be examined for jaundice at least every 8 to 12 hours for the first day of life. Any infant who appears jaundiced in the first 24 hours should have bilirubin levels measured immediately. This can be done with a skin or blood test. Diagnosis of neonatal jaundice

15. Ask 5 questions – What is the birth weight? What is the gestation? What is the postnatal age in hours? Is the jaundice physiological or pathological? Well or ill? Approach to a jaundiced baby

16. H/O Jaundice, Exchange Blood transfusion / Kernicterus in previous sibling Mother – O group or Rh –ve Jaundice – Within 24 hrs or after 72 hrs Trunk distinctly yellow stained Sick jaundiced baby Jaundice persisting > 2 weeks Yellow coloured urine or clay coloured stools Indication for lab investigations (In high risk infants)

17. Laboratory tests (must in all*) Serum bilirubin total and direct* Blood group and Rh for mother and baby* Direct Coomb’s test on infant Hematocrit*, Reticulocyte count Peripheral smear for RBC morphology, evidence of hemolysis and, reticulocyte count Sepsis screen Liver and thyroid function tests in cases with prolonged jaundice TORCH titres

18. Management of jaundice is directed towards reducing the level of bilirubin and preventing CNS toxicity. 1. Prevention of hyperbilirubinemia i. Early and frequent feeding ii. Adequate hydration 2. Reduction of bilirubin: This is achieved by phototherapy or/and exchange transfusion. Management of jaundice

19. Treatment is usually not necessary. Keep the baby well-hydrated with breast milk or formula. Encourage frequent bowel movements by feeding frequently. The following options are currently available for treatment unconjugated hyperbilirubinemia: Phototherapy Exchange transfusion Drugs

20. White light tubes 6-8*/ 4 blue light tubes Cradle or incubator Eye shades * May use 150 W halogen bulb 22 Phototherapy equipment

21. Babies under phototherapy Baby under conventional phototherapy Baby under triple unit intense phototherapy

22. It is a standard mode of therapy for immediate treatment of severe hyperbilirubinemia to prevent kernicterus and to correct anemia in erythroblastosis fetalis. Exchange transfusion

23. Thank you