Neonatal jaundice presentation

PRESENTATION FOR Bsc. honors nursing students

1. NEONATAL JAUNDICE CLASS PRESENTATION ON PRESENTED TO : MRS.RAJITHA MA’AM TUTOR PRESENTED BY : SHRUTI SHARMA BSC HONORS NURSING 3rdYEAR PRESENTED ON : 14 DECEMBER 2020

2. INTRODUCTION Jaundice is the visible manifestation of hyperbilirubinemia . T he clinical jaundice in neonates appear on the face at a serum bilirubin level more than 5 mg/dl , whereas in adults ,it is diagnosed as little as 2mg/ dl.The yellowish discolouration is first seen on the skin of face , nasolabial folds and tip of nose in the neonates .

3. It is detected by blanching the skin with digital pressure in the natural light. Neonatal jaundice is termed as icterus neonatorum or as neonates hyperbilirubinemia .Almost 60 percent of term neonates and about 80 percent preterm neonates have bilirubin >5mg/dl in the first week of life and 6 percent of term babies will have bilirubin levels exceeding 15mg/dl .

4. DEFINITION Neonatal jaundice is a yellowing of a baby’s skin and eyes .Neonatal jaundice is very common and can occur when babies have a high level of bilirubin ,a yellow pigment produced during normal breakdown of red blood cells.

5. Physiological jaundice Pathological jaundice Breast milk jaundice Breast feeding jaundice   TYPES OF NEONATAL JAUNDICE

6. Physiological jaundice

7. It appears in between 30 to 72 hours of age in term babies and in preterm babies may appear earlier but not before 24 hours of age Maximum intensity of jaundice is found on the 4 th day in term babies and 5 th to 6 th day in preterm babies . Serum bilirubin does not exceed 15mg/dl. Usually disappears by 7 th to 10 th day in term babies and by 14 th day in preterm babies. Subsides spontaneously and no treatment is needed.

8. Mother needs arrangement for exclusive breastfeeding for adequate hydration and reassurance. Careful observation for signs of complications along with essential neonatal care are important. May aggravated by prematurity, asphyxia, hypothermia ,infections and drugs.

9. PATHOLOGICAL JAUNDICE

10. Clinical jaundice appears within 24 hours of birth and persist more than one week in term babies and babies more than 2 weeks in preterm babies . Bilirubin level is increasing by more than 5mg/dl per day or 0.5mg/dl per hour. Total bilirubin level is more than 15mg/dl( hyperbilirubinemia ). Palms and soles are yellow. Stool clay or white colored and urine is staining clothes.

11. BREAST milk jaundice

12. Although breast milk jaundice is quite rare ,it often causes concern in part because why it happen is unclear .There may be differences in the infant’s reabsorption of the bilirubin , or in the mother’s milk. Breast milk jaundice can appear 2-5 days after birth. Bilirubin levels peak around 10-14 days but they may remain high for several weeks ,even as much as 3 months. If the bilirubin level continues to climb ,the baby’s health care provider may suggesting donor breast milk or formulae until jaundices resolves.in rare cases ,breastfeeding may be interrupted for 24 hours, in an effort to reduce the bilirubin level.

13. BREAST FEEDING JAUNDICE

14. Also called as “ lack of breastfeeding jaundice or starvation jaundice” this is caused by frequent or ineffective breastfeeding. It is result of too little breastfeeding and therefore low caloric bilirubin metabolism and transport. All of this cause bilirubin levels to be higher in the infant’s blood .Formula milk is no “cure all” for this kind of jaundice ;the key is to make sure your child is taking enough calories.

15. ETIOLOGY

16. PHYSIOLOGICAL JAUNDICE

17. Increased bilirubin load on hepatic cells Defective bilirubin conjugation Defective uptake of bilirubin Defective bilirubin excretion Multiple factors are responsible for the physiological jaundice which commonly found in both term and preterm babies.This is elevation of unconjugated bilirubin concentration due to various reasons in the first week of life. The possible etiology for physiological jaundice are as follows:-

18. PATHOLOGICAL JAUNDICE

19. Pathological jaundice also caused by :- A bout 5 percent of neonates develop pathological jaundice. Appearance of jaundice within 24 hours of age is always pathological. Some causes of this condition may appear after 72 hours, though age of appearance of jaundice may overlap. Investigation should be done to ruled out the exact cause of pathological jaundice .

20. In severe hemolysis Excessive destruction of RBCs due to hemolytic diseases of newborn Defective conjugation of bilirubin

21. Failure to excrete the conjugated bilirubin Miscellaneous : viral hepatitis, malaria, intrauterine infections hypothyroidism, alpha thalaseemia ,drug therapy (vitamin K, salicylates )

22. Rh-immunization is also called as erythroblastosis fetalis , a major cause of severe hyperbilirubinemia . Rh- incompatibility

23. It occurs commonly in ‘O’ group mother and ‘A’ or ‘B’ group fetus . it is milder than Rh – hemolytic disease and may occur even in first born baby. The disease can be diagnosed by examining cord blood for elevation of serum bilirubin and presence of maternal IgG anti ‘A’ or anti ‘B’ antibodies . Direct coomb ‘s test generally negative or weekly positive . ABO- incompatibility

24. MINOR GROUP INCOMPATIBILITY : Immunization can occur for minor groups incompatibility like kidd , Duffy etc OTHER CAUSES : Insufficiency in infant reabsorption of bilirubin Infrequent or ineffective breastfeeding

25. PATHOPHYSIOLOGY

26. CLINICAL MANIFESTATIONS Unconjugated bilirubin may penetrate brain cells by crossing blood brain in some circumstances and results in neurological dysfunction and death. Bilirubin level should be monitored to present the following complications in neonates:-

27. Transient encephalopathy :- It is reversible neurologic complication suspected in increasing lethargy along with rising bilirubin levels. Recovery is possible with prompt initiation of management and exchange blood transfusion.

28. KERNICTERUS

29. Kernicterus:- it is a pathological condition of brain due to toxicity by unconjugated bilirubin. It occurs as a result of necrosis of neurons in basal ganglia ,hippocampal cortex, subthalamic nuclei and cerebellum followed by gliosis of the areas. The cerebral cortex usually is not affected. Other lesions include necrosis of renal tubular cells, intestinal mucosa and pancreatic cells which may present as GI bleeding or hematuria.

30. OTHER MENIFESTATIONS ARE: P oor sucking Lethargy Hypotonia P oor or absent Moro reflex A lteration of consciousness Fever H igh pitch cry C onvulsions Twitching N ystagmus

31. Medical management

32. Management of neonatal jaundice is aimed of reduction of serum bilirubin level within safe limit and prevention of CNS toxicity as kernicterus and brain damage .The management include: Prevention of Rh-isoimmunization by anti-D gamma globulin to RH-negative mother in case of birth of Rh- positive baby. Reduction of bilirubin level by phototherapy and exchange blood transfusion and prevention of bilirubinemia. Reduction of enterohepatic circulation by drug therapy

33. PHOTOTHERAPY It is non invasive , inexpensive and easy method of degradation of unconjugated bilirubin by photo-oxidation. The light waves converted the toxic bilirubin into water soluble non –toxic from which is easily excreted from the blood in the bile , stool and urine .Phototherapy also enhances hepatic excretion of unconjugated bilirubin into the intestinal lumen.

34. Double surface phototerapy can be far more effective management,when the infant is placed on a optic fibre cool biliblanket . Maximum spectral irradiance or flux is 4 to 6 UW/cm square/nm to be maintained on infant skin and should be checked every 100-200hours. It should be discontinued when serum bilirubin is less than 10mg/dl for 2 times .

35. DRUG THERAPY IN NEONATAL JAUNDICE The drugs have very little role in the treatment of neonatal jaundice.They act by interfering with heme -degradation , acceleration method pathway of bilirubin clearance and by inhibiting enterohepatic circulations. The drug which can be used to bind unconjugated bilirubin in the gut and prevent its recirculation are charcoal , agar , polyvinyl pyrrolidone and cholestyramine .

36. EXCHANGE BLOOD TRANSFUSION EBT is most effective and reliable method for reduction of bilirubin level in case of severe hyperbilirubinemia to prevent kernicterus and to correct anemia. Combining phenobarbitone with phototherapy is no more effective than phototherapy alone and hence not used in routine clininals practices .

37. Nursing MANAGEMENT

38. Nursing diagnosis and interventions

39. 1. Fluid volume deficit r / t inadequate fluid intake, ph ototherapy , and diarrhea. INTERVENTIONS Record the number and quality of stool Monitor skin turgor Monitor intake output Give breastfeeding or bottle-feed.

40. 2 . Increased body temperature r / t effects of phototherapy . INTERVENTIONS Give a neutral ambient temperature Keep the temperature between 35.5 - 37 ° C Check vital signs every 2 hours.

41. 3 . Impaired skin integrity r / t hyperbilirubinemia and diarrhoea . INTERVENTIONS Assess skin color every 2 hours Monitor direct and indirect bilirubin Change positions every 2 hours Massage prominent area Keep your skin clean and moisture.

42. 4 . Impaired parenting r / t separation INTERVENTIONS Bring the baby to the mother for breastfeeding Encourage parents to talk to their children Involve parents in care when possible Encourage parents to express feelings.

43. 5 . Risk for injury r / t effects of phototherapy INTERVENTIONS Place the neonate at a distance of 45 cm from the light source Let the baby naked except for the eyes Genital area and buttocks covered with a fabric that reflects light Assess the presence of conjunctivitis every 8 hours 

44. 6 . Anxiety : parents r / t therapy given to Infants . INTERVENTIONS Assess the client's knowledge of family Explain the process of therapy and treatment Give health education on how to care of the baby at home.

45. Administration of anti-D immunoglobulin to the Rh-negative mother having Rh-positive baby to prevent Rh- isoimmunization . Minimizing fetomaternal bleeding during pregnancy Prevention of perinatal distress – like hypoxia, hypothermia, hypoglycemia PREVENTION

46. Adequate and early feed to prevent dehydration and hypoglycemia to reduce enterohepatic recirculation Avoidance of jaundice aggravating drugs like vitamin K in large doses Aspiration of cephalohematoma , if presents with jaundice Management of Rh-sensitized mother during antenatal period with rising titer of indirect Coomb’s test

47. COMPLICATIONS COMPLICATIONS OF PHOTOTHERAPY The immediately problems D ehydration H ypothermia L oose stool or green stool Electric shock S kin rash Hypocalcemia

48. Long term problems like sexual maturation ,retinal damage and rarely skin cancer Bronze baby syndrome :It is dark brown pigmentation of the skin ,mucous membrane and urine following phototherapy

49. COMPLICATIONS OF EXCHANGE BLOOD TRANSFUSION Immediate complications C ardiac failure Tetany Sepsis H yperkalemia U mbilical or portal vein perforation H ypoglycemia, T hrombocytopenia etc . DELAYED COMPLICATIONS INCLUDE: extrahepatic hypertension, portal vein thrombosis ,HIV etc.

50. summarizing