NEONATAL JAUNDICE .pptx

Neonatal Jaundice and hyperbilirubinemia, exchange transfusion ,phototheraphy @pediatric Nursing @Neonates
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1. Case Scenario A New-born baby born with 2kg weight, baby’s condition was well and stable. After 3 days of birth of baby, the mother has noticed yellowish discoloration of the whole body and sclera. During the first two days stools were said to be dark in color which has turned clay color by the 3rd day .

2. NEONATAL JAUNDICE Swaraj Suman MSc. 1 st year student

3. What is the Neonatal Jaundice? Neonatal Jaundice(also called Newborn jaundice) is a condition marked by high levels of bilirubin in the blood. The increased bilirubin cause the infant's skin and whites of the eyes (sclera) to look yellow.

4. Neonatal Jaundice Visible form of bilirubinemia Adult sclera >2mg / dl Newborn skin >5 mg / dl Incidence Occurs in 60% of term and 80% of preterm neonates However, significant jaundice occurs in 6 % of term babies

5. Special characteristic in neonates 1.More bilirubin produced Much more Hemolysis The life-length of Hemolysis(70~80)

6. Special characteristic in neonates 2.The low capability of albumin on unconjugated bilirubin transportation Acid intoxication Less albumin in neonates

7. Special characteristic in neonates 3.The low capability of hepatocyte The primary development of Hepato-enzyme system Easy-broken hepato-enzyme system After-born, the blood glucose level is very low.

8. Special characteristic in neonates 4.High workload of the hepato-enteric circulation Less bacterial Low enzymatic activity in intestine

9. Increased RBC’s Shortened RBC lifespan Immature hepatic uptake & conjugation Increased enterohepatic Circulation Pathogenesis

10. Physiological jaundice Characteristics Appears after 24 hours Maximum intensity by 4th-5th day in term & 7th day in preterm Serum level less than 15 mg / dl Clinically not detectable after 14 days Disappears without any treatment Note: Baby should, however, be watched for worsening of jaundice Teaching Aids: NNF NJ - 11

11. Pathological jaundice Appears within 24 hours of age Increase of bilirubin > 5 mg / dl / day Serum bilirubin > 15 mg / dl Jaundice persisting after 14 days Stool clay / white colored and urine staining clothes yellow Direct bilirubin> 2 mg / dl Teaching Aids: NNF NJ - 12

12. Difference between pathological and physiological Jaundice ?????

13. Causes of jaundice Appearing within 24 hours of age Hemolytic disease of NB : Rh, ABO Infections: TORCH, malaria, bacterial G6PD deficiency Appearing between 24-72 hours of life Physiological Sepsis Polycythemia Concealed hemorrhage Intraventricular hemorrhage Increased entero-hepatic circulation Teaching Aids: NNF NJ - 15

14. Causes of jaundice After 72 hours of age Sepsis Cephalo-hematoma Neonatal hepatitis Extra-hepatic biliary atresia Breast milk jaundice Metabolic disorders Teaching Aids: NNF NJ - 16

15. Common causes in India Physiological Blood group incompatibility G6PD deficiency Bruising and cephalo-hematoma Intrauterine and postnatal infections Breast milk jaundice Teaching Aids: NNF NJ - 17

16. Grading

17. Clinical assessment of jaundice Area of body Bilirubin levels mg/dl Face 4-8 Upper trunk 5-12 Lower trunk & thighs 8-16 Arms and lower legs 11-18 Palms & soles > 15 Teaching Aids: NNF NJ - 19

18. How to measure Use a TC bilirubinometer in babies with Gestational age of 35 weeks or more and postnatal age of > 24 hours. If a TC bilirubinometer is not available, measure the serum bilirubin. If a TC bilirubinometer measurement > 250 umol/l (15 mg/dl) ……….. Check the result by measuring the serum bilirubin.

19. Approach to jaundiced baby Birth weight Gestation and postnatal age Assess clinical condition (well or ill) Physiological or Pathological Look for evidence of kernicterus* in deeply jaundiced Newborn *Lethargy and poor feeding, poor or absent Moro's, opisthotonos or convulsions. Teaching Aids: NNF NJ - 21

20. Diagnosis Maternal & perinatal history Physical examination Laboratory tests (must in all) Total & direct bilirubin* Blood group and Rh for mother and baby* Hematocrit, retic count and peripheral smear* Sepsis screen Liver and thyroid function TORCH titers, Liver scan when conjugated hyperbilirubinemia Teaching Aids: NNF NJ - 22

21. Management Rationale: reduce level of serum bilirubin and prevent bilirubin toxicity Prevention of hyperbilirubinemia: early feeds, adequate hydration Reduction of bilirubin levels: phototherapy, Exchange transfusion, Drugs Teaching Aids: NNF NJ - 24

22. Mechanism of phototherapy Photo-oxidation Configurational isomerization- Water – soluble E-Z isomers Structural isomerization- lumirubin Out of 3 mechanism structural isomerization is most effective.

23. Principle of phototherapy Native bilirubin Photo isomers of bilirubin Insoluble Soluble NJ - 26 460-490nm of light

24. Phototherapy Technique Perform hand wash. Place baby naked in cradle or incubator. Fix eye shades/cover. Keep baby at least 45 cm from lights. Start phototherapy NJ - 27

25. Phototherapy Frequent extra breast feeding every 2 hourly. Turn baby after each feed. Temperature record 2 to 4 hourly. Weight record- daily. Monitor urine frequency. Monitor bilirubin level.

26. NJ - 29 Key point in the practical execution of phototherapy 1. The infant should be naked except for diaper , eye to be covered 2. Distance between the skin and light source (30-45cm) . 3. When used spotlight , the infant is placed in centre . 4. Routinely add 10-15% extra fluid . 5. Timing of follow –up and serum bilirubin testing must be individualized.

27. Lights used in phototherapy 1. Micro white halogen Light 2. Fluoro- 2 blue and 2 white fluorescent lights Types of Phototherapy unit Single surface unit Double surface unit Triple surface unit

28. NJ - 31

29. Side effects of phototherapy Increased insensible water loss Loose stools Skin rash Bronze baby syndrome Hyperthermia Upsets maternal baby interaction May result in hypocalcemia Teaching Aids: NNF NJ - 32

30. Exchange Transfusion Removing affected infants blood and simultaneously replacing with aliquots of compatible donor blood. Aliquots of blood = Small volumes of blood

31. Indications ABO incompatibility Rh isoimmunization Indirect serum bilirubin- 20mg/100 ml or more during first 5 days of life. Septicemia DIC Life threatening metabolic disorders Acute renal and hepatic failure Poisoning Symptomatic Polycythemia Teaching Aids: NNF

32. Method 1. I nfants stomach should be emptied before transfusion to prevent aspiration. 2. V ital signs monitored. 3. With strict aseptic technique, the umbilical vein is cannulated with catheter. 4. Aspiration of 20ml of infant blood alternating with infusion of 20ml of donor blood . 5 . Goal- An isovolumetric exchange of approximately two blood volumes of the infant . Eg. - Double-volume exchange- 2 x blood volume = 2 x 80 cc/kg = 160 cc/kg

33. Choice of blood for exchange blood transfusion ABO incompatibility Use O blood crossmatched against infant serum. In less severe cases- Identify ABO group of both mother and baby. Rh isoimmunization In Emergency- O Rh negative blood without crossmatching. In anticipated Rh sensitized infant birth- O Rh negative blood crossmatched against maternal serum.

34. Criterions for Blood exchange transfusion : 1. Transfuse blood as fresh as possible . 2. Maintained at a temperature between 35 and 37 ° C throughout the exchange transfusion. 3. K ept well mixed and by gentle squeezing or agitation of the bag to avoid sedimentation.

35. Types of exchange transfusion Three types of exchange transfusion are commonly used: A) Two- volume exchange B) Partial exchange ( For treatment polycythemia or anemia ) C) Intrauterine exchanges A one volume exchange transfusion results in removal of 70% to 75% of the neonates RBC. A two volume exchange replaces 90% the optimal volume for an exchange transfusion is twice the infant’s blood volume.

36. Two- volume exchange

37. Contd.. Traditionally, the rule of “10/30” was followed for RBC transfusion, according to which  a Hb level of 10 g/dl or a hematocrit of 30% was recommended in surgical patients . Blood components must be transfused within 4 hours of issue . If the transfusion is interrupted for any reason, administration must be discontinued after 4 hours even if the transfusion is not complete.

38. Complications of exchange transfusion 1 . Anemia 2. Cholestasis 3. Inspissated bile syndrome 4. Portal vein thrombosis 5. Portal hypertension

39. DRUGS to treat neonatal jaundice Phenobarbitone - Induces liver enzymes-increases conjugation Metalloporphyrins - Inhibits heme oxygenase IVIG - Inhibits hemolysis Oral agar agar &cholestyramine- decreases entero-hepatic circulation Albumin infusions-increases bilirubin binding

40. Metalloporphyrins Metalloporphyrins are  inhibitors of the rate-limiting enzyme, heme oxygenase, in the pathway of heme degradation leading to bilirubin production . Tin mesoporphyrin has been most extensively studied in human infants and has been shown to reduce the need for phototherapy.

41. Kernicterus Kernicterus is damage to the brain centers of infants caused by increased levels of unconjugated-indirect bilirubin which is free (not bound to albumin).

42. Journal Review Hyperbilirubinemia in Neonates: Types, Causes, Clinical Examinations, Preventive Measures and Treatments: A Narrative Review Article 2016(May) - Sana ULLAH , 1   Khaista RAHMAN , 2  and  Mehdi HEDAYATI 3,* Methods - The main databases including Scopus, Pubmed , MEDLINE, Google scholar and Science Direct were researched to obtain the original papers related to the newborns’ hyperbilirubinemia. The main terms used to literature search were “newborns’ hyperbilirubinemia”, “newborns’ jaundice”, “Physiological Jaundice” and “ Patholigical Jaundice”. Results - Neonatal jaundice due to breast milk feeding is also sometimes observed. Hemolytic jaundice occurs because of the incompatibility of blood groups with ABO and Rh factors, when the fetus and mother blood groups are not compatible and the fetus blood crosses the barrier of the umbilical cord before birth causing fetus blood hemolysis owing to severe immune response. Conclusion: Jaundice is easily diagnosable however require quick and on the spot treatment. If not treated properly, it leads to many complications. Currently the treatment options for jaundice include photo therapy, chemotherapy, and vaccinations.

43. summary