Neonatal Jaundice.pptx pediatrics presentation

Neonatal jaundice pediatrics

1. NEONATAL JAUNDICE AMY TREESA JAMES P 63

2. INTRODUCTION Important problem in the first week of life. Dermal staining- yellow discoloration, cephalocaudal direction. High bilirubin levels- toxic to central nervous system & cause neurological impairment. Visual assessment- every 12hr during initial 3 to 5 days of life, can be supplemented with TcB (Transcutaneous bilirubinometry). 60 % of term newborns-visibly jaundiced in 1 st week of life but mostly benign. 5-10%-phototherapy or other therapeutic options.

3. PHYSIOLOGICAL VS PATHOLOGICAL JAUNDICE Physiological Jaundice : Physiological immaturity to handle increased bilirubin production. Visible jaundice-appears between 24-72 hrs. TSB peaks in 3 days, then falls in term neonates. Pathological Jaundice : Appears within first 24 hrs of life. Elevation of TSB level, exceeds 5mg/ dL on first day, 10 mg/ dL in second day, 15 mg/ dL thereafter. Clinical jaundice-beyond 3 weeks. Conjugated bilirubin.

4. CAUSES Hemolytic: Rh/ABO incompatibility G6PD deficiency Thalassemia Hereditary spherocytosis Non-Hemolytic: Prematurity Extravasated blood Inadequate feeding Polycythemia Idiopathic Breast milk jaundice

5. CAUSES <24 hrs: Pathological Hemolytic disease Infections 24-72 hrs Physiological Sepsis Polycythemia Concealed hemorrhages Increased enterohepatic circulation >72 hrs Sepsis Neonatal hepatitis Extrahepatic biliary atresia Breastmilk jaundice Metabolic disorders

6. COMMON CAUSES OF JAUNDICE DEPENDING UPON DAY OF APPEARANCE DAY DAY 1 DAY 2 AFTER DAY 3 AFTER THE FIRST WEEK TYPE OF JAUNDICE BLOOD GROUP INCOMPATIBILITY PHYSIOLOGICAL JAUNDICE SEPSIS BREAST MILK JAUNDICE, HYPOTHYROIDISM, NEONATAL HEPATITIS

7. PHYSIOLOGICAL JAUNDICE Over two thirds of all normal newborns. After 1 st day of life-accumulation of unconjugated bilirubin. Peaks in 3-4 days and disappears in 7-10 days. CAUSES Increased bilirubin production. Immaturity of hepatic conjugation. Delayed establishment of effective breastfeeding. Defective uptake and excretion of bilirubin. TREATMENT No need of any specific treatment.

8. PRESENCE OF ANY OF FOLLOWING SIGNS-PATHOLOGICAL JAUNDICE Clinical jaundice- before 24 hrs of age Serum bilirubin rise->5mg/ dL /day Serum bilirubin rise->15mg/ dL Clinical jaundice beyond 14 days of life Clay-/white colored stool and/or dark urine staining the clothes yellow Direct bilirubin >2mg/ dL at any time

9. BREASTFEEDING JAUNDICE Exclusively breastfed- different pattern of physiological jaundice than artificially fed babies. Inadequate breastfeeding. Appears: 24-72 hrs. Peaks: 5-15 days. Disappears: third week of life. 1/3 rd cases: mild jaundice in 3 rd week- persists into 2nd/3 rd month of life. Ensure optimum breastfeeding. BREASTMILK JAUNDICE 2-4% cases-jaundice in excess of 10 mg/ dL beyond 3 rd /4 th week of life . Milk contain inhibitors of conjugation( Pregnanediol , non esterified long chain fatty acids) Diagnosis, if this is unconjugated(mild unconjugated hyperbilirubinemia). Rule out other causes . Continue breastfeeding. Needs no treatment rarely p hototherapy .

10. RISK FACTORS FOR SEVERE HYPERBILIRUBINEMIA Jaundice observed-first 24hrs Blood group incompatibility Gestational age 35-36 weeks Previous sibling received phototherapy Cephalohematoma Inadequate breastfeeding East Asian race

11. DANGERS OF HYPERBILIRUBINEMIA KERNICTERUS Unconjugated bilirubin can cross the immature Blood Brain Barrier [BBB]. SYMPTOMS Lethargy Loss of Moro reflex Poor feeding Intracranial involvement High pitched cry Bulging fontanel Seizures Opisthotonos If Infant survives Choreoathetoid cerebral palsy Mental retardation Paralysis of upward gaze High-frequency hearing impairment

12. CLINICAL EVALUATION

13. APPROACH-AN INFANT WITH JAUNDICE visual assessment every 12 hrs, first 3-5 days ; TRANSCUTANEOUS IF AVAILABLE.

14. INVESTIGATIONS FIRST LINE Total serum bilirubin. Blood groups of mother and baby. Peripheral smear: Evidence of hemolysis. SECOND LINE Direct Coombs test: Antibody coating on fetal RBC. Hematocrit: Decreased in hemolysis. Reticulocyte count: Increased in hemolysis G6PD levels. Others: Sepsis screen, thyroid function test, rule out other genetic enzyme deficiencies.

15. CLINICAL ESTIMATION KRAMER’S DERMAL STAINING OF BILIRUBIN : Examine in good daylight. Cephalocaudal direction. Blanch with digital pressure -skin of forehead, chest, abdomen, thighs, legs, palms , soles & underlying color of skin and subcutaneous tissue noted. Staining of palms and soles-danger sign.

16. According to dermal zone of staining- approximate TSB levels are:

17. CUT-OFFS FOR TREATMENT IN PRETERMS: GESTATION (COMPLETED WEEKS) PHOTOTHERAPY [TSB-mg/ dL ] EXCHANGE TRANSFUSION [ TSB- mg/ dL ] <28 weeks 5-6 11-14 28-29 weeks 6-8 12-14 30-31 weeks 8-10 13-16 32-33 weeks 10-12 15-18 34 weeks 12-14 17-19

18. CLINICAL HISTORY Suggests Obstructive jaundice if Greenish-yellow jaundice Acholic(pale) stools High coloured urine Itching Suggests Haemolytic jaundice if Lemon yellow jaundice Yellow stools Normal coloured urine No itching

19. PROLONGED JAUNDICE Beyond 3 weeks(10mg/ dL ). COMMON CAUSES: Inadequate feeding Breast milk jaundice Extravasated blood Hemolytic disease G6PD deficiency Hypothyroidism IF THE BABY HAS DARK URINE OR SIGNIFICANT JAUNDICE, RULE OUT: Cholestasis Hemolysis, G6PD screen Hypothyroidism Urinary tract infection

20. MANAGEMENT

21. PHOTOTHERAPY Mainstay of treating hyperbilirubinemia. Converts insoluble bilirubin (unconjugated) into soluble isomers that can be excreted in urine or feces. Blue-green light (460-490 nm) of high irradiance. Acts by several ways: Configurational isomerism. Structural isomerism. Photo oxidation.

22. TYPES OF PHOTOTHERAPY LIGHTS Fluorescent lamps of different colors and shapes(CFLs) Halogen bulbs High intensity LEDs (blue)-long life, high irradiance Fibro-optic light sources

23. PROCEDURE Ensure optimum room temperature: 25-28 degree Celsius. Keep the baby in a cot/ bassinet/ incubator/ radiant warmer. Remove all clothes of baby except diaper . Expose maximal surface area of body. Avoid blocking of light by any equipment. Cover baby’s eyes with an eye patch. Keep the distance between baby and light 30-45 cms. Ensure optimum breastfeeding. Minimize interruption of phototherapy during feeding sessions or procedures. Monitor temperature of baby every 2-4 hours. Measure TSB levels every 12-24 hrs. Discontinue once two TSB values 12 hours apart fall below current age-specific cut offs. Monitor for rebound rise within 24 hrs after stopping phototherapy.

24. ADVERSE EVENTS OF PHOTOTHERAPY Diarrhoea Rash Dehydration Hyperthermia Bronze baby

25. EXCHANGE TRANSFUSION Double Volume Exchange Transfusion(DVET) should be done if TSB levels reach to age specific cut-off for ET or signs of bilirubin encephalopathy is seen. INDICATIONS Cord bilirubin: 5mg/ dL or more. Cord Hb is 10mg/ d L or less. ET performed by pull and push technique through umbilical venous route . Umbilical catheter should be inserted.

26. MEDICATIONS IV immunoglobulin-protecting sensitized red cells from getting hemolysed.

27. FOLLOW-UP Serum bilirubin>20mg/ dL Require ET BERA done at 3 months of age

28. PREVENTION Antenatal maternal blood grouping. Ensure adequate breast feeding. Parent education regarding danger signs. High-risk babies.

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