Physiological jaundice

basics of physiological jaundice

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2. Physiological Jaundice Presented By: Nirsuba gurung

3. General objective At the end of this teaching learning session students will be able to know in detail about physiological jaundice 08-Mar-17 9:39 AM Nirsuba gurung 3

4. Specific objective At the end of the class students will be able to define jaundice and physiological jaundice; explain the physiology of physiological jaundice; enlist the causes of physiological jaundice; enlist the risk factor associated with physiological jaundice; 08-Mar-17 9:39 AM Nirsuba gurung 4

5. Contd………. verbalise the sign and symptom of physiological jaundice; describe the assessment and diagnosis of physiological jaundice; describe the management and care of a baby with physiological jaundice. 08-Mar-17 9:39 AM Nirsuba gurung 5

6. Jaundice: A yellow discolouration of the skin, sclera and mucous membrane due to an increase in the serum bilirubin level. This becomes clinically evident when serum bilirubin reaches about 5-7 mg/dl 08-Mar-17 9:39 AM 6 Nirsuba gurung

7. The yellow discoloration of the skin is first noted in the face and as the bilirubin level rises proceeds caudal to the trunk and then to the extremities.

8. Physiological jaundice Jaundice occurring in most newborns, this mild jaundice is due to the immaturity of the baby's liver, which leads to a slow processing of bilirubin. 08-Mar-17 9:39 AM Nirsuba gurung 9

9. Physiological jaundice: Most neonates develops visible jaundice due to elevation of unconjugated bilirubin concentration during 1 st week . This common condition is called physiological jaundice. 08-Mar-17 9:39 AM 10 Nirsuba gurung

10. Physiological Jaundice 50-60% Term Babies Occurs at day 3 Peaks at day 5 Lasts until approximately day 8 Bilirubin levels should not exceed 200 μ mol/l 10% require phototherapy. 08-Mar-17 9:39 AM 11 Nirsuba gurung

11. Contd……. The pattern of hyperbilirubinemia in physiological jaundice has been classified into two functionally distinct periods; Phase 1: last for 5 days in term infants and about 7 days in preterm infants when there is rapid rise in serum levels to 12 to 15 mg/ dl,respectively . 08-Mar-17 9:39 AM 12 Nirsuba gurung

12. Phase two - In phase two bilirubin levels decline to about 34  μmol /l (2 mg/ dL ) for two weeks, eventually mimicking adult values. Preterm infants - phase two can last more than one month. Exclusively breastfed infants - phase two can last more than one month. 08-Mar-17 9:39 AM 13 Nirsuba gurung

13. Physiology of jaundice Blood heme+globulin biliverdin +CO bilirubin reductase bilirubin 08-Mar-17 9:39 AM 14 Nirsuba gurung

14. Pathway of Bilirubin After the liver, the bilirubin enters the gall bladder and is excreted in bile into the intestine. In the gut under the action of bacteria bilirubin is reduced to urobilinogen, a small proportion is excreted in urine with the majority excreted in faeces as stercobilinogen. An enzyme β glucuronidase is also present in the gut and converts conjugated bilirubin back to unconjugated bilirubin. There is 10times the amount of β glucuronidasae in the neonate compared with the adult. 08-Mar-17 9:39 AM 15 Nirsuba gurung

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16. Facts: 1gm Hb=35 mg of bilirubin Normal newborn=8.5+-2.3 mg/kg/day In adult:3.6 mg/kg/day 08-Mar-17 9:39 AM 17 Nirsuba gurung

17. Causes of Physiological Jaundice Short life span of fetal red blood cells Change from fetal cells to adult cells Insufficient albumin to bind to the excess unconjugated bilirubin , leads to free unconjugated fat soluble bilirubin . Sterile gut Poor peristalsis allows the β glucuronidase to hydrolyse the conjugated bilirubin back to un-conjugated bilirubin which then goes back to the liver for further metabolism. Immature liver that reduces the hepatic metabolism 08-Mar-17 9:39 AM 18 Nirsuba gurung

18. Causes condt… Higher levels of red blood cells, which is more common in small-for-gestational age (SGA) babies and some twins 08-Mar-17 9:39 AM Nirsuba gurung 19

19. Other Risk Factors For Jaundice Breast feeding Asian /Greek Delay in clamping the cord, increasing the volume of blood Bruising – caput, cephalhaematoma Prematurity Low birth weight Drug Hypoglycemia & hypothermia 20 Nirsuba gurung

20. Signs and Symptoms of Jaundice Discoloration of the skin, sclera Lethargy Poor feeding Yellow urine and stool Irritability 08-Mar-17 9:39 AM 21 Nirsuba gurung

21. Complications of Jaundice High levels of bilirubin — usually above 25 mg — can cause deafness, cerebral palsy, or other forms of brain damage in some babies. Risk that the fat soluble bilirubin crosses to the brain to cause Bilirubin Encephalopathy known as Kernicterus. 08-Mar-17 9:39 AM 22 Nirsuba gurung

22. Assessment of Physiological Jaundice Clinical observation. Jaundice visible at 5-7 mg/dl . Jaundice is caudal in direction, i.e. from head down the body. Kramer’s rule 08-Mar-17 9:39 AM 23 Nirsuba gurung

23. Kramer's Rule Zone 1 2 3 4 5 SBR ( umol /L) 100 150 200 250 >250 08-Mar-17 9:39 AM 24 Nirsuba gurung

24. Kramer’s rule 08-Mar-17 9:39 AM Nirsuba gurung 25

25. Investigation Clinical history of mother/family. History of bruising / cephalohematoma / birth trauma. Blood grouping and rhesus factor. Feeding pattern. Infection. Drugs. 08-Mar-17 9:39 AM 26 Nirsuba gurung

26. Management No action for the vast majority of babies with physiological jaundice Measure the Serum Bilirubin The level of serum bilirubin actually indicates what treatment is required: To continue to observe but no additional intervention Repeat test Phototherapy Exchange blood transfusion (unlikely for physiological jaundice) 08-Mar-17 9:39 AM 27 Nirsuba gurung

27. Medical Management Phenobarbital Increases liver metabolism and thus lowering bilirubin levels. 08-Mar-17 9:39 AM Nirsuba gurung 28

28. Phototherapy First discovered, accidentally, at Rochford Hospital in Essex, England Ward sister of the premature baby unit firmly believed that the infants under her care benefited from fresh air and sunlight in the courtyard When serum bilirubin was checked   indicated a much lower level of bilirubin tha earlier 08-Mar-17 9:39 AM Nirsuba gurung 29

29.  Dr. Cremer's published the facts in the  Lancet  in 1958 08-Mar-17 9:39 AM Nirsuba gurung 30

30. Mode of action Isomerization that changes trans-bilirubin into the water-soluble cis-bilirubin isomer. 08-Mar-17 9:39 AM Nirsuba gurung 31

31. Blue-green light in the range of 460-490 nm is most effective for phototherapy. The absorption of light by the normal bilirubin (4Z,15Z-bilirubin) generates configuration isomers, structural isomers, and photooxidation products. 08-Mar-17 9:39 AM Nirsuba gurung 32

32. Factors affecting dose of phototherapy Irradiance of light used, The distance from the light source, and The amount of skin exposed. 08-Mar-17 9:39 AM 33

33. Standard phototherapy is provided at an irradiance of 8-10 microwatts per square centimeter per nanometer ( mW /cm2 per nm). Intensive phototherapy is provided at an irradiance of 30 mW /cm2 per nm or more (430–490 nm).

34. For intensive phototherapy, an auxiliary light source should be placed under the infant. The auxiliary light source could include a fiber-optic pad, a light-emitting diode (LED) mattress, or a bank of special blue fluorescent tubes. Term and near-term infants should receive phototherapy in a bassinet and the light source should be brought as close as possible to the infant, typically within 10-15 cm.  08-Mar-17 9:39 AM Nirsuba gurung 35

35. Guidelines for management of hyperbilirubinemia in healthy, full-term infants (American Academy of Pediatrics) Age 25-48 hours**: >12 -Consider phototherapy >15 -Initiate phototherapy >20 -Initiate exchange transfusion if intense phototherapy* fails >25 -Initiate exchange transfusion 08-Mar-17 9:39 AM Nirsuba gurung 36

36. Age 49-72 hours >15 -Consider phototherapy >18 -Initiate phototherapy >25 -Initiate exchange transfusion if intense phototherapy* fails >30 -Initiate exchange transfusion Age >72 hours >17 -Consider phototherapy >20 -Initiate phototherapy >25 -Initiate exchange transfusion if intense phototherapy* fails >30 -Initiate exchange transfusion 08-Mar-17 9:39 AM 37 Nirsuba gurung

37. An example of an action chart for bilirubin results www.ich.ucl.ac.uk/clinical_information/clinical_guidelines/downloads/phototherapy.pdf 08-Mar-17 9:39 AM 38 Nirsuba gurung

38. INDICATIONS OF PHOTOTHERAPY AND EBT: PROTOCOL BPKIHS 08-Mar-17 9:39 AM 39 Nirsuba gurung

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40. Care of baby Early feeding/ Nutrition/ Hydration Increase frequency of breast feeding Neutral thermal environment Prevent hypoglycaemia and hypoxia Avoid constipation Hygiene 08-Mar-17 9:39 AM 41 Nirsuba gurung

41. Summary 08-Mar-17 9:39 AM Nirsuba gurung 42

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43. Reference Ghai . OP.Essential Paediatric. 6 th edition CBS publication and distributors page no:169-171 Dutta D.C. Text book of obstretics. 7 th edition.New book agency(p)ltd page no:476 08-Mar-17 9:39 AM Nirsuba gurung 44

44. Contd…….. College of Family Physicians of Canada (1999) Approach to the management of hyperbilirubinemia in term newborn infants paeditrics & Child Health 4(2); 161-164 http://www.cps.ca/english/statements/FN/fn98-02.html (retrived on 11 dec 2o11)   08-Mar-17 9:39 AM Nirsuba gurung 45

45. Contd…… Dutta Parul. Paediatric Nursing. 2 nd edition Jaypee brothers mediccal publisher(p) ltd page no:313-314. 08-Mar-17 9:39 AM Nirsuba gurung 46

46. Multiple choice questions 1.physiological jaundice starts to appear on: A. At the time of birth; B. 2-3 day of life; C. 7 days of life; D. 15 days of life 08-Mar-17 9:39 AM Nirsuba gurung 47

47. 2.End product of R.B.C destruction which causes yellowish discoloration of body is: Globulin Albumin Biliverdin Bilirubin 08-Mar-17 9:39 AM Nirsuba gurung 48

48. 3. Conjugation of bilirubin takes place in: Intestine Lung Liver kidney 08-Mar-17 9:39 AM Nirsuba gurung 49

49. 4. All of the following are the causes of physiological jaundice, except: Sterile gut Short life span of R.B.C Constipation Mature liver 08-Mar-17 9:39 AM Nirsuba gurung 50

50. 5. Jaundice first appears in Foot Hands Sclera of eyes abdomen 08-Mar-17 9:39 AM Nirsuba gurung 51

51. Assignment While you are posted in pediatric ward:1 a 5 days old baby is having serum total bilirubin level 10 mg/dl , and not sucking breast milk . Make a nursing care plan for the baby. 08-Mar-17 9:39 AM Nirsuba gurung 52

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