NNJ

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1. Neonatal Jaundice
Dr MuzammilKoshish
DCH, DNB Resident,
JLN Hospital and Research
Centre, Bhillai.

2. 2
Neonatal Jaundice
Learning Objectives:
Define hyperbilirubinemia.
Differentiate between physiological and
pathological jaundice.
Causes of hyperbilirubinemia.
Discuss the pathophysiology of
hyperbilirubinemia.
Complication of hyperbilirubinemia.
The three elements of therapeutic
management.
Plan of care if baby has
hyperbilirubinemia.

3. 3
Neonatal Jaundice
(Hyperbilirubinemia)
Definition: Hyperbilirubinemia refers to
an excessive level of accumulated
bilirubin in the blood and is
characterized by jaundice, a yellowish
discoloration of the skin, sclerae,
mucous membranes and nails.
Unconjugated bilirubin = Indirect
bilirubin.
Conjugated bilirubin = Direct bilirubin.

4. 4

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

6. 6
Bilirubin metabolism
Hb →globin + haem
1g Hb = 34mg bilirubin
Non –heme source
1 mg / kg
Bilirubin
glucuronidase
Bilirubin
Bilirubin
Ligandin
(Y -acceptor)
Bil glucuronide
Intestine
Bil
glucuronide
Stercobilin
bacteria
βglucuronidase

7. 7
Bilirubin Production & Metabolism

8. 8
Clinical assessment of jaundice
Area of body Bilirubin
levels
mg/dl (*17=umol)
Face 4-8
Upper trunk 5-12
Lower trunk & thighs 8-16
Arms and lower legs 11-18
Palms & soles > 15

9. 9
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 jaundice.

10. 10
Why does physiological
jaundice develop?
Increased bilirubin load.
Defective uptake from
plasma.
Defective conjugation.
Decreased excretion.
Increased entero-hepatic
circulation.

11. 11
Age in Days
Term
Preterm
1 2 3 4 5 6 10 11 12 13
14
15
10
5
Bilirubin level
mg/dl
Course of physiological
jaundice

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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

13. 13
Causes of jaundice
Appearing within 24 hours of
age
Hemolytic disease of NB : Rh,
ABO
Infections: TORCH, malaria,
bacterial
G6PD deficiency

14. 14
Causes of jaundice
Appearing between 24 -72
hours of life
Physiological
Sepsis
Polycythemia
Intraventricular hemorrhage
Increased entero-hepatic
circulation

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Causes of jaundice
After 72 hours of age
Sepsis
Cephalhaematoma
Neonatal hepatitis
Extra-hepatic biliary atresia
Breast milk jaundice
Metabolic disorders.

16. 16
Risk factors for jaundice
JAUNDICE
J-jaundice within first 24 hrs of life
A -a sibling who was jaundiced as
neonate
U -unrecognized hemolysis
N –non-optimal sucking/nursing
D-deficiency of G6PD
I -infection
C–cephalhematoma /bruising
E -East Asian/North Indian

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Diagnostic evaluation:
Normal values of unconjugated B.
are 0.2 to 1.4 mg/dL.
Investigate the cause of jaundice.

18. 18
Clinical Jaundice
Measure Bilirubin
Bilirubin>12mg/dL Bilirubin<12mg/dL
And Infant <24-h old and Infant >24-h old
Coomb’s test Follow Bilirubin
Positive Coomb’s Negative Coomb’s
Identify Antibody
•Rh
•ABO
•KELL, etc. Direct Bilirubin

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Direct Bilirubin
Direct Bilirubin >2; Consider: Direct Bilirubin <2
Hepatitis
Intrauterine, Viral, or
Toxoplasmic infections Hematocrit
Biliary obstruction
Sepsis
Galactosemia
Alpha-1-antitrypsin deficiency Normal or Low High
Cystic fibrosis (Polycythemia)
Tyrosinosis
Cholestasis
Hyperalimentation
Syphillis RBC Morphology
Hemochromatosis Reticulocyte count

20. 20
RBC Morphology
Reticulocyte count
Abnormal: Normal:
Spherocytosis -Enclosed hemorrhage
Elliptocytosis -Increased Enterohepatic
Stomatocytosis Circulation
Pyknocytosis -Breast Milk Jaundice
ABO incompatibility -Hypothyroidism
Red cell enzyme deficiency -Criglar-Najjar Syndrome
Alpha Thalassemia -Infant of Diabetic mother
Drugs (eg. Penicillin) -RDS
DIC -Asphyxia
-Infection
-Gilbert Syndrome
-Drugs (eg. Novobiocin)
-Galactosemia (Early)

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Medical Care ofneonatal
jaundice

22. 22
Phototherapy
Exchange transfusion
Drugs
Diet
Medical Care

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Phototherapy
Is the primary treatment .
Was discovered in England in the
1950s.

24. 24
Why Phototherapy is
effective?
Three reactionscan occur when
bilirubin is exposed to light :
 Photo-oxidation
 Photo-isomerization
 Structural isomerization

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Factors That Affect the Dose
and Efficacy of Phototherapy
Wavelength
Irradiation level
Distance
Bilirubin concentration
Nature and character of the light
source

26. 26
Wavelength
 Bilirubin absorbs light primarily
around 450 nm, typically 425 to 475
nm
 In practice, light used in
wavelengths : white, blue, and
green

27. 27
Irradiation level
A dose-response relationship
exists

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29. 29
Distance
Distance should not be greater than
50 cm (20 in)
Can be lessif the infant's
temperature is monitored.
Energy delivered decreases with
increasing distance .

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31. 31
The efficiency of phototherapy
increases with :
-serum bilirubin concentration.
-skin surface
Bilirubin concentration

32. 32
Nature and character of the
light source
Wide Spectrum
 Quartz halide spotlights
 Green light
 Blue fluorescent tubes
Narrow-spectrum
Ordinary
 White (daylight) fluorescent tubes
 White quartz lamps
 Fiberoptic light

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Indications for phototherapy
In most neonatal wards, total serum
bilirubin levelsare used as the primary
measure of risk for bilirubin
encephalopathy.
The 2004 AAPguidelines represent a
significant change from the 1994
guidelines.
The emphasis on preventive action
and risk evaluationis much stronger.

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35. 35
Key points in the practice
Maximizingenergydelivery
Maximizing the available surface
area.

36. 36
Intermittent Versus
Continuous Phototherapy ?
Clinical studies have produced conflicting
results.
Individual judgment should be
exercised.
If the infant’s bilirubin level is approaching
the exchange transfusion zone ,
phototherapy should be administered
continuously until a satisfactory decline in
the serum bilirubin level occurs or
exchange transfusion is initiated.

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What about insensible water
loss?
New data suggest that if temperature
homeostasis is maintained, fluid loss is
not increased significantly by
phototherapy.
In infants who are fed orally, the preferred
fluid is milk, since milk serves as a
vehicle to transport bilirubin out of the
gut.

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Timing of follow-up
serum bilirubin ?
 In infants admitted with extreme
serum bilirubin values ( 30 mg/dL):
monitoring should occur every hour or every
other hour.---------Reductions in serum
bilirubin values (5 mg/dL/h).
 In infants with more moderate
elevations of serum bilirubin: monitoring
every 6-12 hours .

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Expectations regarding
efficacy of phototherapy ?
 Bilirubin concentrations are still rising-----a
significant reduction of the rate of increase .
 Bilirubin concentrations are close to their
peak-----phototherapy should result in measurable
reductions in serum bilirubin levels within a few hours.
In general, the higher the starting serum bilirubin
concentration, the more dramatic the initial rate of
decline.

40. 40
When discontinuation of
phototherapy?
When serum bilirubin levels fall (1.5-3
mg/dL)below the level that triggered the
initiation of phototherapy.
Serum bilirubin levels often rebound, and
follow-up tests should be obtained within
6-12 hoursafter discontinuation.

41. 41
What about
prophylactic Phototherapy ?
No purpose
In general, the lower the serum
bilirubin level, the less efficient the
phototherapy.

42. 42
Phototherapy complications
Phototherapy is very safe, and it may have no serious long -
term effects in neonates .
Insensible water lossis not as important as previously believed.
Loose stools.
Bronze baby syndrome
Retinal damage
Effects on cellular genetic material
in vitro and animal data have not been shown any implication for
treatment of human neonates.
However, most hospitals use cut-down diapers during phototherapy .

43. 43
Skin blood flow is increased--redistribution of blood flow may
occur in small premature infants--Increased incidence of
patent ductus arteriosus (PDA) has been reported
But this effect is less pronounced in modern servocontrolled
incubators.
Hypocalcemia in premature infants . It has been
suggested that this is mediated by altered melatonin metabolism.
Deterioration of certain amino acids in total parenteral
nutrition (TPN) solutions.
Shield TPN solutions from light as much as possible.
Accidentshave been reported, including burns resulting from
failure to replace UV filters.
Phototherapy complications

44. Babies under phototherapy
Baby under conventional
phototherapy
Baby under triple unit intense
phototherapy

45. 45
Exchange
transfusion

46. 46
What are indications of
Exchange transfusion?
Avoiding bilirubin neurotoxicity
when other therapeutic
modalities have failed.
In addition, even in the absence of
high serum bilirubin levels, the
procedure may be indicated in infants
with erythroblastosis .

47. 47
Exchange transfusion has
been performed because of :
 Cord hemoglobin <11 g/dL
 Cord bilirubin > 4.5 mg/dL
 Rapid rate of increase in bilirubin >1 mg/dL/h
 More moderate rate of increase in bilirubin> 0.5
in the presence of moderate anemia Hb=11 -13
 Hemolytic jaundice with bilirubin > 20
or a rate of increase that predicted this level
(fear of 20) .

48. 48
Why Exchange transfusion
become a rare procedure ??
Immunotherapy in Rh -negative women
So ,ABO incompatibility has become the most
frequent cause of hemolytic disease in
industrialized countries.
Effective phototherapy
Recently,immunotherapy has been
introduced as treatmentin the few
remaining sensitized infants. Results are
promising

49. 49
When exchange transfusion
should be performed ?
When phototherapy does not
significantly lower serum bilirubin
levels
Intensive phototherapy is strongly
recommended in preparation for an
exchange transfusion. do not await
laboratory test results in these cases .

50. 50

51. 51
Complications of Exchange
transfusion
Hypocalcemia and hypomagnesemia
Hypoglycemia
Acid-base disorder
Hyperkalemia
Cardiovascular
Bleeding
Infections
Hemolysis
Temperature dysreguation

52. 53
DRUGS

53. 54
What about Phenobarbital ?
an inducer of hepatic bilirubin
metabolism
 Several studies have shown that
phenobarbital is effective .
 Phenobarbital may be
administered :
-pre-natally in the mother or
-post-natally in the infant.
 However, concerns exist regarding
the long-term effects of phenobarbital on
these children.

54. 55
What about IV immunoglobulin
(500 mg/kg) ?
Significantly reduce the need for
exchange transfusions in infants
with isoimmune hemolytic
disease.

55. 56
New therapy :
Mesoporphyrins and Protoporphyrins
Currently under development
Inhibition of bilirubin production through
blockage of heme oxygenase.
Apparently, heme can be excreted
directly through the bile .
This approach may virtually eliminate
neonatal jaundice as a clinical problem.
But …

56. 57
Important questions
before the treatment can be applied
 Long-term safety ?.
 Complete understanding of
putative role for bilirubinin light of
data suggesting that bilirubin may
play an important role as a free
radical quencher ( anti-oxidant )?

57. 58
DIET
Temporary interruption of
breastfeeding…
It is not recommended
unless serum bilirubin levels reach 20 mg/dL

58. 59
Supplementation with dextrose
solution
 It is not recommended
because
-it may decrease caloric intake
-it may decrease milk production
-it may accelerate enterohepatic
circulation and consequently
delay the drop in serum bilirubin
concentration

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What is
the recommendation ?
 Increase breastfeeding to 8 -12
times per day
 Breastfeeding can also be
supported with manual or electric
pumpsand the pumped milk given
as a supplement to the baby.

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When infants can be
discharged ?
When they are :
-feeding adequately and
-demonstrating a trend towards
lower values.
Auditory functiontests prior is
advisable in infants who have had
severe jaundice.

61. 62
How to manage infants released
within the first 48 hours of life ?
In the era of early dischargein recent
years, a number of infants have developed
kernicterus---
Infants need to be reassessed for
jaundice within 1-2 days.
Use of hour-specific bilirubin nomogram
may assist in selecting infants .

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63. 64
Do infants need follow-up
obsevation after Bilirubin falls?
Infants with hemolytic jaundice
require follow-up observation for
several weeksbecause
hemoglobinlevels may fall lower
than seen in physiologic anemia.
Erythrocyte transfusions may be
required if infants develop
symptomatic anemia.

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Finally…What about
Prognosis ?
Prognosis is excellent if the patient
receives treatment according to accepted
guidelines.
The increased incidence ofkernicterus in
recent years may be due to the
misconception that jaundice in the healthy
full-term infantis not dangerous and can
be disregarded.

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The goals of planning
Infant should receive appropriate
therapy if needed to reduce
serum bilirubin levels.
Infant should experience no
complications from therapy.
Family should receive emotional
support.
Family should be prepared for
discharge and home based care.

66. 67
References
American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia.
Management of hyperbilirubinemia in the newborn infant 35 or more
weeks of gestation. Pediatrics. 2004;114:297-316
Johnson LH, Bhutani VK, Brown AK. System -based approach to
management of neonatal jaundice and prevention of kernicterus. J
Pediatr. 2002;140:396-403
American Academy of Pediatrics, Steering Committee on Quality
Improvement and Management. Classification of recommendations for
clinical practice guidelines. Pediatrics. 2004;114:874-877
Gartner LM, Herschel M. Jaundice and breastfeeding. Pediatr Clin
North Am. 2001;48:389-399
Moyer VA, Ahn C, Sneed S. Accuracy of clinical judgment in neonatal
jaundice. Arch Pediatr Adolesc Med. 2000;154:391-394
Ip S, Glicken S, Kulig J, Obrien R, Sege R, Lau J. Management of
Neonatal Hyperbilirubinemia. Rockville, MD: US Department of Health
and Human Services, Agency for Healthcare Research and Quality;
2003. AHRQ Publication 03-E011
Bhutani VK, Johnson LH, Sivieri EH. Predictive ability of a predischarge
hour-specific serum bilirubin for subsequent hyperbilirubinemia in
healthy term and near-term newborns. Pediatrics. 1999;103:6-14.
American Academy of Pediatrics, Subcommittee on Neonatal
Hyperbilirubinemia. Neonatal jaundice and kernicterus. Pediatrics.
2001;108:763-765

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Thank You!