NEONATAL JAUNDICE.pptx By SASIRAVI Msc

this presentation id based upon the Neonatal jaundice, NORMAL
METABOLISM
OF BILIRUBIN ,RISK FACTORS,CLASSIFICATION OF JAUNDICE, PHYSIOLOGICAL JAUNDICE OF NEONATES, CAUSES OF PHYSIOLOGICAL JAUNDICE,PATHOLOGICAL JAUNDICE, cay=use of pathological jaundice, breast milk jaundice, conjucated hyperbilirumia, unconjugated hyperbilirubimia, general symptoms of neonatal jaundice, diagnostic feature,managemnet of neonatal jaundice and phototherapy,and nursing care. PHOTOTHERAPY
It is a method of treating jaundice in which a baby is placed under source of blue-green light and the light react with bilirubin in the blood through the skin of the baby.
It is noninvasive, inexpensive and
easy method.
The light waves convert the toxic
bilirubin into water-soluble
nontoxic and excreted from the
blood in the bile, stool and urine.
RECOMMENDATION :
Light’s wavelength - range of 420 to 600 nm
Light source is fixed over crib or
incubator or it can be portable type.
Distance - 45 cm from the skin in case
of fluorescent light, 15 to 20 cm – CFL, 35 cm – LED
Started when serum bilirubin approaches 15 mg/dl.
In preterm babies, phototherapy is started at a serum bilirubin level of 5 mg/dL
Fluorescence or halogen light.
Led light source are used presently for effective phototherapy, TECHNIQUE OF PHOTOTHERAPY:
Baby's eyes - covered to prevent retinal damage
Diaper to be kept - cover the genitals
Position should be changed every two hours
Temperature must be recorded two hourly
More frequent (2 hourly) breastfeeding.
Baby's bodyweight should be recorded once a day.
Constant observation should be made for urine, green or loose stool, skin rash, behavior change, convulsions and features of any complications.
Serum bilirubin level must be estimated at least every 12 hours.
Discontinued - serum bilirubin level are less than 10 mg/dL for two times, The immediate problems are,
Dehydration,
Hypothermia,
Hyperthermia,
Loose stool or green stool,
Bronze-baby- syndrome,
Electric shock,
Skin rash,
Hypocalcemia, etc., PROCEDURE OF EBT:
Strict aseptic technique by the expert team members in a well-equipped set-up.
The process is very slow and continued over an hour.
The baby must be kept warm and well-restraint.
The stomach contents should be aspirated.
Baby's cardiac status and temperature should be monitored continuously
Umbilical vein or artery is used and cannulated for the procedure.
Peripheral vein or artery can also be used. Air tight blood transfusion set with four ways stopcock are required
Rinsed with heparinized saline (10 units of heparin/mL).
The donor blood should be at normal body temperature (37°C).
Accurate record of in and out amount of blood should be maintained strictly.
Exchange blood transfusion chart to be maintained, POSTEXCHANGE CARE
Close monitoring of - baby's condition, phototherapy, antibiotics (if asepsis is at suspect), warmth, routine essential care, bilirubin estimation.

1. NEONATAL JAUNDICE R. SASIRATHA , MSc NURSING TUTOR

2. DEFINITION : Neonatal jaundice is defined as yellowish discoloration of skin, sclera and mucus membrane. Icterus appear on face when serum bilirubin level exceeds 5 mg/ dL . Total bilirubin: 0.1 to 1.2 mg/ dL Direct (conjugated ) bilirubin: less than 0.3 mg/ dL Around 60% term and 80% preterm neonate develop neonatal jaundice during first week of life.

3. NORMAL METABOLISM OF BILIRUBIN

4. Red blood cells die off in large number after birth Because the liver is not yet mature , it processes bilirubin very slowly Avery little bilirubin leaves the body A lot of bilirubin is created The excess, unprocessed bilirubin builds up everywhere in the body. It colours the skin and eyes yellow BABY HAS JAUNDICE

5. NORMAL ABNORMAL

6. RISK FACTORS Mnemonic "JAUNDICE" J: Jaundice within first 24 hours of life A: A sibling who was jaundiced as neonate U: Unrecognized hemolysis N: Non-optimal sucking D: Deficiency of G6PD I : Infection C: Cephalohematoma /bruising E: East Asian/North Indian.

7. NEONATAL JAUNDICE UNCONJUGATED HYPERBILIRUBINEMIA CONJUGATED HYPERBILIRUBINEMIA PATHOLOGICAL BREAST MILK HEPATIC PHYSIOLOGICAL HEMOLYTIC POST HEPATIC NON- HEMOLYTIC CLASSIFICATION OF JAUNDICE

8. PHYSIOLOGICAL JAUNDICE OF NEONATES Appears after 24 hours. Maximum intensity by 4th-5th day in term and 7th day in preterm  Serum level <15 mg/dl. Clinically not detectable after 14 days Disappears without any treatment .

9. CAUSES OF PHYSIOLOGICAL JAUNDICE Increased bilirubin load on liver cells. Increased erythrocyte volume   Decreased erythrocyte survival . Defective hepatic uptake of bilirubin from plasma . Defective bilirubin conjugation . Inappropriate bilirubin excretion.  

10. 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 .

11. CAUSES OF PATHOLOGICAL JAUNDICE Over production of bilirubin . Increased hemolysis. Rh compatibility. ABO incompatibility. G6PD(glucose-6-phosphate  dehydrogenase )   deficiency . Non- hemolytic causes . Birth trauma: IVH, cephalhematoma . Polycythemia : Fetomaternal transfusion, twin-twin transfusion, pyloric stenosis .

12. Decreased excretion of bilirubin. Biliary atresia. Metabolic causes Genetic disorders. Drugs .

13. BREAST MILK JAUNDICE 2% - 3% of exclusively breastfed term babies The jaundice appears at the end of the first week of life It can last for up to 2 months. If bilirubin is <15 mg/ dL at 3 weeks one need not worry . But if bilirubin is >15 mg/ dL at 3 weeks , Cessation of breast milk for 48 hours Phototherapy will be required in higher level.

14. CONJUGATED HYPERBILIRUBINEMIΑ When conjugated bilirubin level is >2.0 mg/ dL resulting from failure to excrete conjugated bilirubin from hepatocyte to duodenum . Child have, Hepatomegaly, splenomegaly, Pale stool and high coloured urine Causes : Liver injury due to hepatitis, toxic substances, metabolic problems. Severe hemolytic disease. Biliary atresia.

15. UNCONJUGATED HYPERBILIRUBINEMIA Due to Rh-incompatibility, ABO-incompatibility , H ereditary Spherocytosis, G6PD deficiency, Alpha-thalassemia, Vitamin K3 induced hemolysis , Sepsis, Pyloric stenosis Large bowel obstruction, Hypothyroidism and Breast milk jaundice .

16. GENERAL SYMPTOMS OF NEONATAL JAUNDICE Yellow skin Yellow eye or sclera Sleepiness Poor feeding Brown urine Fever High pitch cry Vomiting

17. DIAGNOSIS : History collection ; Previous babies with neonatal jaundice, exchange blood transfusion, Maternal illness with viral infections, maternal drug intake, Maternal blood group and Rh factor

18. Physical examination Yellowish discoloration of skin and mucous membrane Kramer’s rule I 4-8mg/dl II 5-12 III 8-16 IV 11-18 V >15

19. Ingram ictero -meter Instrument is pressed over the nose. C olor of the blanched skin is matched with the appropriate yellow strip and the level of jaundice is assessed by the marked level of bilirubin Transcutaneous bilirubinometry costly and sophisticated equipment used to measure the intensity of jaundice by reflecting light rays on the blanched skin .

20. Invasive blood sampling Serum bilirubin level, (total, conjugated and unconjugated ), Hb %, serum albumin , RBC morphology, blood culture , acid-base level, liver and thyroid function tests, TORCH titers, G6PD deficiency, etc. “BILICAM” - Application used via a smartphone camera to assess the severity by a photograph .

21. MANAGEMENT OF NEONATAL Aim : A t reduction of serum bilirubin level within safe limit. P revention of CNS toxicity and brain damage. Prevention of Rh- isoimmunization by anti-D gamma- globulin to Rh-negative mother in case of birth of Rh- positive baby or abortion. Exclusive breast feeding Phototherapy and Exchange blood transfusion Drug therapy : To bind unconjugated bilirubin in the gut and to prevent its recirculation by, C harcoal , agar, polyvinyl pyrrolidone and cholestyramine

22. PHOTOTHERAPY It is a method of treating jaundice in which a baby is placed under source of blue-green light and the light react with bilirubin in the blood through the skin of the baby. It is noninvasive, inexpensive and easy method. The light waves convert the toxic bilirubin into water-soluble nontoxic and excreted from the blood in the bile, stool and urine.

23. MECHANISM : Structural isomerization : Convert the bilirubin to lumirubin which is excreted in urine Photo isomerization : Transforms the unconjugated bilirubin molecule into hydro-soluble isomers. Photo oxidation : Converts bilirubin to small polar products that are excreted in urine

24. Types of phototherapy : Continuous phototherapy Intermittent phototherapy Intensive phototherapy Types of phototherapy unit : Single surface unit Double surface unit Triple surface unit Bili -blanket

25. RECOMMENDATION : Light’s wavelength - range of 420 to 600 nm Light source is fixed over crib or incubator or it can be portable type . Distance - 45 cm from the skin in case of fluorescent light, 15 to 20 cm – CFL, 35 cm – LED Started when serum bilirubin approaches 15 mg/dl. In preterm babies, phototherapy is started at a serum bilirubin level of 5 mg/ dL Fluorescence or halogen light. Led light source are used presently for effective phototherapy

26. TECHNIQUE OF PHOTOTHERAPY: Baby's eyes - covered to prevent retinal damage Diaper to be kept - cover the genitals Position should be changed every two hours Temperature must be recorded two hourly More frequent (2 hourly) breastfeeding. Baby's bodyweight should be recorded once a day. Constant observation should be made for urine, green or loose stool, skin rash, behavior change, convulsions and features of any complications. Serum bilirubin level must be estimated at least every 12 hours. D iscontinued - serum bilirubin level are less than 10 mg/ dL for two times

27. The immediate problems are , Dehydration, Hypothermia, Hyperthermia, Loose stool or green stool, Bronze-baby- syndrome, Electric shock, Skin rash, Hypocalcemia, etc. Long- term problems, Retinal damage and Skin cancer (rare ). COMPLICATIONS OF PHOTOTHERAPY:

28. EXCHANGE BLOOD TRANSFUSION (EBT): An exchange transfusion is a medical procedure that’s done by removing and replacing blood with blood or plasma from a donor. It is given when phototherapy fails to prevent a rise in bilirubin to toxic levels.

29. INDICATIONS FOR EBT Cord blood hemoglobin level-10 g/ dL or less. Cord blood bilirubin level-5 mg/ dL or more. Unconjugated serum bilirubin level-10 mg/ dL within 24 hours or 15 mg/ dL within 48 hours. ABO incompatibility

30. NATURE AND AMOUNT OF BLOOD FOR EBT : Rh isoimmunization (Rh-negative , ABO compatible blood is used). ABO-incompatibility (O group, Rh-compatible blood is used). Fresh whole blood collected less than 72 hours is preferred. The quantity of blood used is 160 to 180 mL/kg (to replace 80 to 90% of fetal blood).

31. PROCEDURE OF EBT: S trict aseptic technique by the expert team members in a well-equipped set-up. The process is very slow and continued over an hour. The baby must be kept warm and well-restraint. The stomach contents should be aspirated. Baby's cardiac status and temperature should be monitored continuously Umbilical vein or artery is used and cannulated for the procedure. Peripheral vein or artery can also be used.

32. Air tight blood transfusion set with four ways stopcock are required Rinsed with heparinized saline ( 10 units of heparin/mL ). The donor blood should be at normal body temperature (37°C). Accurate record of in and out amount of blood should be maintained strictly. Exchange blood transfusion chart to be maintained

33. POSTEXCHANGE CARE Close monitoring of - baby's condition, phototherapy, antibiotics (if asepsis is at suspect), warmth, routine essential care, bilirubin estimation. F ollow-up to detect complications and emotional support to the parents and family members .

34. COMPLICATIONS OF EBT: Immediate complications: cardiac failure, air embolism, acidosis, sepsis , hyperkalemia. umbilical or portal vein perforation, hypoglycemia, thrombocytopenia, etc. Delayed complications : extrahepatic portal hypertension, portal vein thrombisis , HIV, hepatitis B and CBinfection , ulcerative colitis, etc.

35. 1. Which of the following factors leads to neonatal Hyperbilirubinemia . High level of unconjugated bilirubin in liverb . Shortened neonatal red cell life spanc . Haemolysis All the above 2 . Phototherapy will be started in term baby when Bilirubin level is. >5mg/dl 10mg/dl 15mg/dl 20mg/dl

36. 3. Lights  used in phototherapy  are Neon   light Fluorescent light Sodium   light LED ligh 4. Which of the following statements regarding phototherapy for jaundice in newborns is correct? Phototherapy is not effective in treating jaundice. Phototherapy helps convert unconjugated bilirubin into a water-soluble form . Phototherapy can be safely administered without monitoring the infant's skin . Phototherapy can only be used in severe cases of jaundice.

37. 4. Which of the following is contraindication for phototherapy hyperbilirubinemia Rh incompatability Bronze-baby- syndrome ABO incompatability 5. Eye shield must be placed over the infant eyes to prevent Eye irritation Conjunctivitis Retinal damage

38. 6. Which  one is the exact mechanism of phototherapy  a.Converting conjugated bilirubin into conjugated unconjugated bilirubin b.Converting  unconjugated bilirubin into conjugated bilirubin c.Excreting conjugated bilirubin from liver d.None of the above

39. 7. Identify image

40. 8. Baby  should be fed ----------- when baby is in phototherapy  a.Every   2 nd hourly   b.Every  3 hours once c.Every 4 hours once d.As necessary

41. THANK YOU R. SASIRATHA , MSc NURSING TUTOR