NEONATAL JAUNDICE CHARACTERISTICS PPPT -

JAUNDICE

1. NEONATAL JAUNDICE

2. OBJECTIVES Definition Metabolism of bilirubin Types of jaundice Causes of neonatal jaundice Management of jaundice

3. Neonatal hyperbilirubinemia Jaundice is the yellow color of the skin and sclerae caused by deposits of bilirubin levels in circulation Incidence Occurs in 60% of term pregnancies 80% of preterm babies within the 1 st week About 10% of exclusively breastfead babies are still jaundiced at one month of age It’s the most common condition in newborns that requires medical attention

4. Bilirubin physiology Bilirubin is a product of breakdown of hemoglobin in the rbc which are aged/immature/malformed which are removed from the circulation and broken down in reticuloendothelial system Hemoglobin from the cells is broken down into the byproducts of haem , globin and iron Haem is converted to biliverdin and then to conjugated bilirubin Globin is broken into amino acids which are used to make proteins Iron is stored in the body and used to make new rbcs Unconjugated bilirubin is transported to the liver where it detaches from bilirubin and combines with glucose glucuronic acid and conjugation occurs using enzyme uridine diphospoglucoronyl transferase Bilirubin is now water soluble and available for excretion

5. types Physiological jaundice-appears few days after birth due to; Incresed bilirubin load Defective conjugation Increased enterohepatic circulation Xtics Appears after 24hours Total bilirubin rises by less than 5mg/dl per day Maximum intensity by 4 th -5 th day in term and 7 th dsy in pre term Serum level less than 15 mg/dl Clinically not detectable after 14 days

6. Pathological jaundice Appears within 24hrs of age Increase of bilirubin >5mg/dl/day Serum bilirubin >15mg/dl Jaundice persisting after 14 days Direct bilirubin >2mg/dl

7. General symptoms Yelow skin Yelow eyes sclera Sleepiness Poor feeding Brown urine Fever High pitch cry Vomittting

8. Physiological jaundice Occurs when there is excessive red blood cells break down Appears after 24 hours Maximum intensity is between the 4 th to 5 th day in term and 7 th day in pre term babies It is apparent on the 3 rd day when unconjugated serum bilirubin is between 25mmol/l to 125mmol/l All new borns have a rise in unconjugated bilirubin during the first few dyas after bith . This is due to: The turnover of hemoglobin is higher in the fetus and the newborn but before birth the bilirubin from the fetus is removed via placenta At birth the more efficient lungs increase oxygen levels, there is hemolysis of excessive rbcs that are not needed At birth, the newborn liver enzymes, such as glucorunic transferase maybe immature and not effective

9. Ctd Excessive hemolysis of red blood cells greater than conjugation Increased enterohepatic reabsorption Decreased albumin binding capacity thus less bilirubin is transported in the liver for conjugation

10. pathophysiology As a result of factors stated above, there is rise in serum unconjugated bilirubin in healthy babies during the first few days after birth. It has a characteristic pattern. The babies on the first day after birth will not appear jaundiced but most will look yellow by day 3-4 As unconjugated bilirubin rises, the serum albumin become saturated and any excess spills over into blood plasma The unconjugated bilirubin is a fat soluble and will deposit in subcutaneous fat making the skin appaear yellow The brain is next especially the basal ganglia

11. ctd High levels of unconjugated bilirubin can potentially be a serious problem because it can cross the bbb and be deppsited in basal ganglia. This can result to bilirubin encephalopathy and in longer resulting to cerebral palsy abd learning disorders Complications Cerebral palsy Seizures kernicterus

12. Causes of concern in physiological jaundice Jaundice in the first 24hours History of antibodies wich may cause red cell hemolysis, identified on maternal screening Any baby who is visibly jaundiced. The serum bilirubin levels should be checked as the visual assessment of jaundice is not sufficiently accurate Any baby who remains jaundiced beyond 14 days of age

13. Early physiological jaundice Occurs within the first five days after birth. This is due to: Hemolysis which maybe either due to issoimmunization or ABO incompatibility Infection Bruising Polycythemia Dehydration

14. Late onset breast mil jaundice This occurs later in the newborn period. The bilirubin levels are usually peak between the 6 th to the 14 th day of life Late onset breast milk may develop in upto one third of healthy breast feed infants. Total serum bilirubin levels vary from 12-20 mg per dl and are non pathogenic The underlying cause is not well understood but is associated with substances in maternal mil such as b- glucorinidase and non esterified fatty acids which may inhibit normal bilirubin metabolism. The bilirubin levels normally falls continousely after infant is 2 weeks old but remain persistently elevated for 1-3 months

15. 2. Pathological jaundice Considered pathological if it presents within the first 24hours after birth and there is rapid rose in serum bilirubin including both obstructive and hemolytic jaundice Causes Caused by disorders that increase bilirubin production and reduces transport tation to and from the liver. They include: ABO incompatibility –when mother is blood group O Rhesus incompatibility – when mother is rhesus negative Sepsis due to infection Membranopathies - spherocytosis Enzymopathies- defect with G-6-P dehydrogenase deficiency Hepatotoxic drugs taken by mother during pregnancy

16. ctd Intrauterine infections Biliary obstruction that prevents transportation of conjugated bilirubin to gastro intestinal system for extraction Asphyxia and birth injuries Syndromes associated with jaundice Crigler - Najjar syndrome type 1 and 2. in type 1, its an autosomal recessive disorder in which no functioning UDPGT-1 is produced where there is prolonged unconjugated hyperbilirubinemia. In type 2 there is less than 5% of normal UDPGT-1 activity Dubin Johnson syndrome- autosomal recessive disorder characterized by a defect in biliary excretion of conjugated bilirubin Gilbert syndrome- a heterogeneous group of disorders that have a common at least a 50% decrease in UDPGT-1 activity as a result of a defect in the gene responsible for this enzyme

17. Diagnosis of neonatal jaundice the baby should be checked for jaundice within 72 hours of being born during the physical examination The caregiver should however check for symptoms of jaundice after returning home since it can sometimes take up to a week to appear .the mother should look out for the yellowing of skin or whites of their babies eyes . Check for the baby’s urine and poo .the baby might have jaundice if their urine is yellow (should be colorless ) or their poo is pale (should be yellow or orange ) Seek medical attention if they suspect the baby may have jaundice Tests will need to be carried out to see whether treatment is needed . Neonatal jaundice is noted when serum bilirubin is >5mg/dl . Early neonatal jaundice is most commonly caused by unconjugated hyperbilirubinemia .

18. Laboratory examination VISUAL EXAMINATION The baby will have a visual examination to look out for signs of jaundice They need to be undressed during this so their skin can be looked at under good, preferably natural light . Other things that may also be checked may include ; the whites of the baby’s eyes , the baby’s gums and the color of the poo or urine .

19. Bilirubin test If jaundice is suspected , the level of bilirubin in their blood will need to be tested . This can be done using ; A small device called a bilirubinometer , which shines light onto the baby’s skin .it calculates how the level of bilirubin by analyzing how the light reflects off or is absorbed by the skin . A blood test of a sample of blood taken by pricking your baby’s heel with a needle .the level of bilirubin in the liquid part of the blood called the serum is then measured . In most cases , a bilirubinometer is used to check for jaundice in babies . Blood tests are usually necessary if the baby developed jaundice within 24 hours of birth or the reading is particularly too high

20. Coombs test There are 2 types of coombs tests ; Direct coombs test Indirect coombs test Direct coombs test It is done on newborns blood sample . The cord blood is taken immediately at birth for hemoglobin , coombs test and bilirubin The test is looking for “foreign “antibodies that are already adhered to the infant’s red blood cells , a potential cause of hemolysis Indirect coombs test This is the test that is done on the mother’s blood as part of her prenatal labs Determine antibodies in serum that can attack red blood cells

21. Rhesus incompatibility Rhesus incompatibility occurs when a mother who is rhesus negative and has naturally occurring anti rhesus negative antibodies in her serum ,gives birth to an infant who is rhesus positive . If any mixing of maternal and fetal blood occurs during pregnancy or the birth process , the mother’s anti Rh antibodies will vigorously attack the baby’s Rh positive red blood cells by adhering to and lysing the cells

22. ABO incompatibilty ABO incompatibility occurs by the same general mechanism . Type O mothers are most commonly impacted , since they carry both anti A and anti-B antibodies . If the infant is type A , type B or type AB , risk for incompatibility exists . If mixing of maternal and fetal blood occurs during pregnancy or the birth process , these antibodies can also attack the baby’s red blood cells and cause hemolysis .

23. Other lab test Peripheral smear for red blood cells morphology Liver and thyroid function tests in cases of prolonged jaundice Screening for sepsis to check whether there is any infection Hematocrit Glucose -6 Phosphate Dehydrogenase deficiency Intrauterine and postnatal infections Osmotic fragility test These tests help to determine whether there is an underlying cause for the raised levels of bilirubin

24. Grading neonatal jaundice Kramer introduced a grading system to quantify neonatal jaundice based on visual assessment of the skin , using grades between 0 and 5 to describe the extent of jaundice progression . This approach assumes that the occurrence of jaundiced skin patches , or dermal icterus , starts from the head and spreads to the hands and feet as jaundice becomes more severe .it relies on the assessor to determine if a skin region is jaundiced or not and provide a maximum extent grade (0-5) to quantify the severity of neonatal jaundice . One difficulty with social assessment of skin color is the presence of melanin which often obscures the yellowness of the skin .

25. Kramer’s grading scale grade extent Range of bilirubin(mg/dl none - 1 Face and neck only 4.8 2 Chest and back 5-12 3 Abdomen below umbilicus 8-16 4 Arms, legs below knees 11-18 5 Hands and feet >15

26. Management of neonatal jaundice PHOTOTHERAPY UV light catalyzes the conversion of trans bilirubin into water soluble bilirubin isomer. NURSING CARE 1. shield the eyes with eye patches– remove during feeds. 2. keep the baby naked. 3. place the baby close to the light source- 45cm distance 4. do not place anything on the phototherapy device- also keep device clean. Dust can carry bacteria and reduce light. 5. promote frequent breastfeeding- disrupt phototherapy. Allows maternal

27. CTD 6. periodically change position supine to prone- reposition after each feed to expose as much surface area of the baby as possible to light. 7. monitor temperature- every 4 hours and weight every 24 hours. 8. periodic plasma/serum bilirubin test( 12-24 hours)- visual testing is unreliable. 9. make sure that each light source is working- fluorescent tubes should be replaced if more than 6 months in use Tube ends have blackened

28. INTRAVENOUS IMMUNOGLOBULIN used with  isoimmune   haemolysis    May help to mop up excessive antibodies, preventing a rapid  rise in bilirubin.   but may slightly increase the risk of needing a later top-up transfusion but these are safer and less invasive.

29. EXCHANGE TRANSFUSION Baby’s blood is removed and replaced with donor’s blood. Done when bilirubin levels are toxic (400-500mol/l) Indications infants with hemolytic disease Preterm babies less than 1500g Preterm with bilirubin levels of 300-400mol/l Healthy term babies with bilirubin levels of 400-500mol/l NURSING CARE Put baby back to phototherapy to continue. Closely observe for bleeding from umbilical cord. Continue infusion for sometime. Reassure mother and involve her in the care of baby.

30. DRUGS Act by interfering with heme degradation accelerating the normal pathway of bilirubin clearance and by inhibiting enterohepatic circulation. Mostly not used but if used, phenobarbital is preferred. – induces hepatic bilirubin metabolism.

31. Nursing management Admission to the NBU and assessment of general condition. Encourage early and frequent breastfeeding to provide glucose to cells and also encourages colonization of the mucosa with normal flora responsible for formation of stercobilinogen for excretion in stool. Monitoring serum bilirubin levels at 12-24 hour interval. Keep baby warm. Assess color of urine and stool. Monitor for signs of kernicterus. Check on general behavior and activity. Observe ability to suck properly. Take temp apex beat. Give antibiotics when indicated.

32. complications Possible complications 1.Cerebral palsy 2.deafness. 3.Kernicterus 4.permanent upward gaze. 5.Improper development of tooth enamel.